A new nurse-led pathway to deliver better patient outcomes post-stroke | nursing times

How nurse specialists revised a stroke care pathway involving internal cardiac monitoring devices ABSTRACT Stroke is a leading cause of death and disability in the UK and one in four stroke

survivors will experience another stroke within five years of their first episode. This has led to an increase in the number of stroke-related readmissions into hospitals across the UK.

Remote patient monitoring and programming, which is available with insertable cardiac monitoring devices, allows healthcare teams to remotely monitor patients; capturing medical data without

needing to arrange an in-clinic visit. Nurse practitioners from University College London Hospitals NHS Foundation Trust developed a pioneering stroke care pathway using this technology,

improving the detection of atrial fibrillation while freeing up vital cardiac resources across the trust. Selina Edwards and Roberto Macarimban-Inglesant from the trust explain how they

helped to revise the stroke care pathway. CITATION: EDWARDS S, MACARIMBAN-INGLESANT R (2024) A new nurse-led pathway to deliver better patient outcomes post-stroke. _Nursing Times_ [Online];

120: 7. AUTHORS: Selina Edwards is advanced stroke nurse practitioner and Roberto Macarimban-Inglesant is nurse practitioner; both at University College London Hospitals NHS Foundation

Trust. * This article has been double-blind peer reviewed * Scroll down to read the article or download a print-friendly PDF here (if the PDF fails to fully download please try again using a

different browser) INTRODUCTION Stroke is a leading cause of death and disability in the UK, responsible for approximately 38,000 deaths each year (National Institute for Health and Care

Excellence (NICE), 2023), and its burden on individuals, families and the NHS will only increase as the population ages with co-morbidities (NICE, 2019). One in four stroke survivors will

experience another stroke (secondary stroke) within five years (NICE, 2019). Based on 1.3 million stroke survivors in the UK alone, this is a staggering 325,000 people who have been, or will

be, affected by a stroke yet again (Public Health Scotland, 2023; Department of Health Northern Ireland, 2021). This has led to an increase in the number of stroke-related readmissions to

hospitals across the UK (King et al, 2020). This article will explore how nurse practitioners transformed the stroke arrhythmia pathway by improving the remote cardiac monitoring process and

creating a nurse-led stroke service. REMOTE MONITORING DEVICES FOR STROKE PATIENTS Of the more than one million stroke survivors living in the UK, a disproportionate number are living with

atrial fibrillation (AF) (Stroke Association, no date). People with AF have a risk of stroke that is around five times higher than those without the condition (Stroke Association, no date).

It is now well known that AF-related strokes are often more severe, with higher mortality and greater disability rates than strokes with other causes (Stroke Association, no date).

Additionally, effective anticoagulation therapy can decrease the rate of stroke by at least two-thirds in people with AF, this is of course only possible in cases where AF has been

identified (Lowres et al, 2019). Remote patient cardiac monitoring and programming, which are available with some insertable cardiac monitoring systems, allow healthcare teams to remotely

monitor patients and remotely reprogram devices, capturing medical data from patients without needing to arrange an in-clinic visit, and transmitting this data electronically to consultants

for clinical assessment. Remote patient monitoring technology can identify several cardiac conditions, including AF, by regularly monitoring cardiac changes such as heart rhythm and heart

rate. This helped consultants at University College Hospitals NHS Foundation Trust (UCLH) to reduce emergency hospital visits for stroke patients, lessening the pressure on its healthcare

systems. Insertable loop recorders or insertable cardiac monitors (ICMs) – also known as implantable cardiac monitors – are chosen for patients who are suspected to be suffering from

arrhythmias or have had a cryptogenic stroke (stroke of an unknown source), including transient ischaemic attack (TIA). The use of long-term cardiac monitoring to support the detection of AF

in cryptogenic stroke and TIA patients is now also recommended by both NICE and the European Stroke Association (NICE, 2020; Rubiera et al, 2022; National Clinical Guideline for Stroke for

the United Kingdom and Ireland, 2023). Consequently, ICMs with remote monitoring and programming can help to improve the quality of life for patients recovering from a stroke, while reducing

the risk of secondary stroke and minimising unnecessary healthcare costs for the NHS (National Clinical Guideline for Stroke for the United Kingdom and Ireland, 2023). PILOTING A NEW STROKE

ARRHYTHMIA PATHWAY Myself, an advanced stroke nurse practitioner at UCLH, and my colleague, nurse practitioner Roberto Macarimban-Inglesant, helped to pioneer a new stroke arrhythmia

pathway and referral system at UCLH, to reduce the referral logistics surrounding patient care within the Barts Health NHS Trust local cardiac tertiary centre. The focus of our pilot was on

“door to detection”, and whether it was completed in a timely and efficient way. On a personal level for both of us, it is rewarding to be able to carry out the procedure of ICM insertion in

a timely way so our patients can feel reassured that their heart rhythm is being constantly monitored to pick up any potential signs of what the problem may be. Aside from pioneering the

new stroke-led service, we were also the first trained stroke nurses surrounding the implantation of these miniature devices across UK. The ICM insertion can be performed by two or three

nurse practitioners (NPs); one NP competent in ICM procedure performs the procedure, and one or sometimes two NPs assist with set-up, programming and documentation. This has transformed the

stroke treatment process at UCLH, while still using Barts’ multidisciplinary team capacity, and so ensuring no compromise to cardiac care of the stroke patients. When we first piloted the

new stroke arrhythmia pathway at UCLH, there were no other hospitals or trained stroke nurse practitioners across the UK using this method. This presented some initial structural challenges

when determining the number of staff needed to carry out the procedure or the finding of a prespecified room. However, we were greatly supported by Barts’ team who had a more established

specialist cardiac care team. Barts invited the UCLH nurse practitioners to observe their existing ICM insertion model and pathway, allowing us to learn more about the process and replicate

a lot of their tried and tested practices. DATA-LED DECISION MAKING Once the new stroke arrhythmia pathway became more established, myself and Roberto Macarimban-Inglesant, alongside other

nurse practitioners, decided to evolve it further. We developed a specialist suspected AF referral process that standardised how the AF patient group was referred to the stroke services.

This allowed us to better quantify its data and develop metrics that paved the way for a more efficient stroke arrhythmia care pathway. We began with a weekly multidisciplinary team triage

for discussion of patient referrals. Suitable candidates for ICMs were then referred to a face-to-face pre-assessment appointment. It was this face-to-face appointment that differed from

Barts’ pathway. At Barts, consultants referred suitable AF patients, offering an appointment after the screening, and then saw the patients face to face on the day of their cardiac

monitoring insertion. Due to the infancy of our pilot study, patients were given an in-person consultation and were able to choose either the Barts care pathway or the UCLH pilot pathway

option. MULTIDISCIPLINARY SUPPORT AND PATIENT REVIEW When our 14-month pilot at UCLH first began in March 2021, it was widely supported by multidisciplinary teams including cardiology and

neurology consultants. From the beginning, we found it reassuring to have stroke consultants present, should they need to step in during the cardiac monitoring insertion. Several nurses had

never completed a small surgical procedure independently. As a result, to begin with there were consultants present at every procedure, overseeing the insertion of the cardiac monitoring

device. An important metric of the pilot study was the stroke patient experience. UCLH wanted to collect as much evidence as possible, via pre- and post-cardiac monitoring insertion

questionnaires. The stroke patient was seen in the clinic for a pre-assessment consultant review, with an assessment questionnaire before having their procedure. This review was supported by

a team from the medical device company who were also on hand to support UCLH with other aspects relating to the cardiac monitoring system and its workflow. We kept patients for an

additional 30 minutes post-insertion, to monitor for signs of any complications, including bleeding, swelling, or pain at the insertion site, before discharging the patients. We also offered

patients a choice of another face-to-face consultation or telephone review four to five days post-insertion for a wound review. We gave patients our direct contact details, for which

patients were encouraged to call if they had any concerns, reinforcing the new patient-centric pathway model. EXCEEDING THE EXPECTED RESULTS Initially, when we began our UCLH pilot study,

our consultant team was asked to refer any suitable candidates. In total, we inserted ICMs in 20 candidates successfully within the pilot period, and detected AF in six patients. The pilot

study resulted in an AF detection rate of 30% within the first six months of remote cardiac monitoring, and an average time from pre-assessment to cardiac monitoring insertion at UCLH of 73

days, compared to the previous one year at Barts. This greatly exceeded our expectations and meant that more cases of AF were detected in stroke patients using ICMs than via the standard

12-lead electrocardiogram (ECG) or other short-term devices, such as the Holter monitor. This meant that consultants could treat the necessary patients with anticoagulants, reducing their

risk of secondary stroke and hospital readmission. The pilot study proved a clear success and several patients emphasised that, because of the ICM, they felt reassured by being constantly

monitored, and were able to return to normal. The reduction in ICM insertion waiting times and positive patient feedback contributed to the continuation of the service, allowing us to evolve

the service past the pilot phase. The recent focus has been on upskilling existing and new stroke advanced nurse practitioners, increasing the team’s capacity and expanding the skill set.

At the time of writing (April 2024), a total of 121 patients have been implanted with the ICM device under this care pathway. AF has been detected in 24 of those patients implanted, all of

whom were started on anticoagulation medication the same day or the next working day. Several healthcare decision-makers are now working with UCLH to provide additional resources, having

recognised that long-term cardiac monitoring can more effectively detect AF than 12-lead ECGs and other short-term devices, and consequently reduce the risk of secondary strokes. Myself,

Roberto, and the rest of the UCLH stroke team are working continually to improve AF patient detection, referral, and review duration, while increasing the number of nurses trained to insert

cardiac monitoring devices. The development of our pilot at UCLH has demonstrated the invaluable role that nurse practitioners hold in stroke patient care. Their willingness to improve

treatment and to expand their surgical skills to support ICM insertion has freed up vital resources across UCLH; allowing consultants to focus on patients who require more complex

procedures. This has improved many lives and continues to reduce costs across UCLH. CONCLUSION The introduction of a care pathway pilot at UCLH allowed stroke nurse practitioners to

undertake advanced skills enabling them to monitor AF in stroke patients by inserting implantable cardiac monitoring devices. The development of this new nurse-led care pathway has offered

post-stroke patients greater reassurance about constant health monitoring plus faster access to anticoagulation therapy, and has also freed up vital resources across UCLH. KEY POINTS * There

are more than 1 million stroke survivors in the UK; a disproportionate number of whom are living with atrial fibrillation * People with atrial fibrillation have a five times higher risk of

stroke than those without * Remote patient monitoring technology can accurately identify atrial fibrillation * Selina Edwards and Roberto Macarimban-Inglesant were the first trained stroke

nurses in the implantation of internal cardiac monitors in the UK * Nurse-led cardiac monitoring insertion has freed up vital resources, allowing consultants to focus on more urgent patients

* Declaration: The pilot was supported by an educational grant from Medtronic. REFERENCES DEPARTMENT OF HEALTH (NORTHERN IRELAND) (2021) _2020/21 Raw Disease Prevalence Trend Data for

Northern Ireland_. Department of Health. KING D ET AL (2020) The future incidence, prevalence and costs of stroke in the UK. _Age and Ageing_; 49: 2, 277–282. LOWRES N ET AL (2019) Reducing

stroke risk in atrial fibrillation: adherence to guidelines has improved, but patient persistence with anticoagulant therapy remains suboptimal. _Korean Circulation Journal_; 49: 10,

883-907. NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE (2023) _Stroke and TIA: What is the prevalence of stroke and TIA in the UK?_ NICE. NATIONAL INSTITUTE FOR HEALTH AND CARE

EXCELLENCE (2020) Implantable Cardiac Monitors to Detect Atrial fibrillation after Cryptogenic Stroke. NICE. NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE (2019)_ NICEimpact Stroke_. 

NICE. NATIONAL CLINICAL GUIDELINE FOR STROKE FOR THE UNITED KINGDOM AND IRELAND (2023) Long-term management and secondary prevention. _strokeguideline.org_ (accessed 24 April 2024). PUBLIC

HEALTH SCOTLAND (2023) _Scottish Stroke Improvement Programme: Annual Report 2023_. PHS. RUBIERA M ET AL (2022) European Stroke Organisation (ESO) guideline on screening for subclinical

atrial fibrillation after stroke or transient ischaemic attack of undetermined origin. _European Stroke Journal_; 7: 3, 107-139. STROKE ASSOCIATION (no date) Atrial fibrillation: information

and resources. _stroke.org.uk_ (accessed 30 May 2024).   HELP NURSING TIMES IMPROVE HELP US BETTER UNDERSTAND HOW YOU USE OUR CLINICAL ARTICLES, WHAT YOU THINK ABOUT THEM AND HOW YOU WOULD

IMPROVE THEM. PLEASE COMPLETE OUR SHORT SURVEY.