Introduction: Atrial fibrillation (AF) is the commonest sustained cardiac arrhythmia. Acute hospital admissions are rising with significant cost and capacity implications. Recent pathway reviews led to service innovations to provide remote out-of-hospital care for patients with haemodynamically stable AF/atrial flutter (Afl) with fast ventricular response. Patients remain in hospital, attached to a heart monitor until rate control is achieved in the current pathway of care. Virtual wards are novel pathways designed to support patients remotely whilst maintaining safe high quality patient care.
Methods: A retrospective analysis of all patients admitted to our centre with a primary diagnosis of AF/Afl between 1 August and 1 September 2021 was carried out. Diagnosis was initially taken from the admission coding system, electronic medical admission records were reviewed and further clarified using medical notes as required. The analysis focused on the number of patients who were haemodynamically suitable, no other indications for hospital admissions or laboratory abnormalities, rendering them candidates for remote management. Patients often present at the emergency department (ED) and are then transferred to the clinical decisions unit (CDU) by ambulance for specialist cardiology support, self-present to CDU or referred by their general practitioner.
Results and intervention: Over the 8-week period, 211 primary diagnosis AF patients were admitted to CDU generating 226 admissions. When the proposed virtual ward criteria (i.e. haemodynamically stable, heart rate <140 bpm, no other acute conditions requiring admission) was applied, 51% (n=105) of patients were identified as suitable candidates for an alternative telemedicine based care model. Out of these 105 patients, 50% (n=53) were transferred from EDs located at a different site, requiring ambulance transfer. In the same period, there were 187 ED attendances with primary diagnosis of AF, 43% (n=80) of which met the virtual ward criteria. Out of these patients, 66% (n=53) were transferred to CDU, 2.5% (n=2) were discharged to alternative destinations, 27.5% (n=22) were suitable for discharge home and 3.7% (n=3) self-discharged due to prolonged waiting times. Setting up the virtual ward model: Patients’ who satisfy the AF virtual ward entry criteria are referred via a dedicated email or by phone. Referrals are triaged and recruited by an Arrhythmia Advanced Clinical Practitioner or Cardiology Registrar. Patients are given an information booklet about the care through the virtual ward along with a single-lead ECG monitoring device (AliveCor), Bluetooth-enabled blood pressure monitor and pulse oximeter. Patients are on-boarded to the digital platform (Dignio), which enables recording of several daily single-lead ECGs, blood pressure, oxygen saturation and a symptom questionnaire. The platform supports video consultations if required. Patients’ clinical data are reviewed by the clinical team at least twice daily and medication changes are recommended with the option of home delivery within 48 hours to prevent patients from returning to hospital.
Conclusions/implications: This new model of care represents a promising pathway for patients presenting acutely to hospital with a primary diagnosis of AF/AFl, where they can be treated at home with outreach support from a specialist team as a ‘Hospital at Home’ virtual ward. This can potentially reduce the significant AF-related pressures on the national health services. ❑
