Audit of the documentation of anti-coagulation decision making for diagnosed atrial fibrillation - PowerPoint Presentation

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Audit of the documentation of anti-coagulation decision making for diagnosed atrial fibrillation in an acute stroke population

Maclennan D, Bartlett S, Cassels A, McBain I, Tompkins K, Mcauley S, Cvoro V; Ward 42, Victoria Hospital, Hayfield road, Kirkcaldy, KY2 5AH e-mail: david.maclennan@nhslothian.scot.nhs.uk

abstract

Aim Audit the documentation of either starting anti-coagulation or not commencing anti-coagulation for atrial fibrillation in an acute stroke unit. Standard: All patients diagnosed with atrial fibrillation should have a decision documented regarding anti-coagulation.Background: Atrial fibrillation is a recognised risk for the development of cardioembolic stroke and is identified in 25% of patients admitted with an ischaemic stroke. Following identification of atrial fibrillation, a decision regarding anti-coagulation should be made and documented clearly.Methods: All sequential r-tapes from 06/01/20 to 06/10/20 results were reviewed for evidence of atrial fibrillation. If atrial fibrillation was identified on the recordings then inpatients notes and associated discharge letters were reviewed for evidence of the initiation of anti-coagulation or a clear decision made to not anti-coagulate. Results:: 101 results were included within the defined study period, of which a total of 52 patients had atrial fibrillation identified. 7 of the patients had known AF and were subsequently excluded. Of the data set, three patients died at the time of atrial fibrillation being recorded, these are included in the discussed column.Conclusion: :Anti-coagulation decisions were not fully documented for all patients with newly diagnosed atrial fibrillation. This has medico-legal implications, as well as implications for secondary stoke prevention.

background

Atrial Fibrillation and ischaemic strokeAtrial fibrillation (AF) is the most common sustained cardiac arrhythmia worldwide with around 1/5 of stroke patient being diagnosed with AF in their lifetime. Atrial fibrillation refers to an irregular atrial tachycardia which may be paroxysmal, permanent or persistent. [1] The development of atrial fibrillation is a risk factor for cardiovascular and non-cardiovascular disease with the most devastating complication of atrial fibrillation being a cardioembolic ischaemic stroke. Patients with established atrial fibrillation have a three-fold increased risk of an ischaemic stroke and 25% of patients admitted with an ischaemic stroke will have atrial fibrillation identified on admission.[2] [3] The identification of atrial fibrillation has important connotations for secondary prevention as the risk of a further cardioembolic stroke event is highest in those with a history of stroke disease. Anti-coagulation for AFIf atrial fibrillation is detected then a decision should be made regarding anti-coagulation. Decisions regarding further anti-coagulaton may be guided by recognized scoring systems (CHADS2VASC and HASBLED) and clinical judgement, along with a discussion with the patient. In the context of an ischaemic stroke, therapeutic anti-coagulation with a direct oral anti-coagulant or warfarin should be considered following two weeks of high dose aspirin treatment. [4]The use of anti-coagulation can reduce future stroke risk by 66% and is an integral part of stroke prevention.

AIMS

The primary aim of the project was to review the documentation of decisions about anti-coagulation when atrial fibrillation was identified in an inpatient stroke population. The expected standard was that all patients with identified AF would have a documented decision about anti-coagulation.

methods

All sequential R-tapes from 06/01/20 to 06/10/20 were reviewed for evidence of atrial fibrillation. R-tape results automatically detect evidence of atrial fibrillation. Recordings that were highlighted as capturing runs of atrial fibrillation were reviewed manually by a stroke consultant. Recordings that did not have a documented review, were reviewed manually for evidence of atrial fibrillationAtrial fibrillation was defined as a cardiac trace recording showing absence of p-wave activity and irregular rhythm. For patient’s that had atrial fibrillation identified, their clinical notes, emergency care summaries and discharge letters were reviewed for evidence of a discussion regarding anti-coagulation or a prescription of an anti-coagulantA documented discussion regarding anti-coagulation or a prescription of a new anti-coagulant was used as the criteria for anti-coagulation discussed. This included patients whereby anti-coagulation was considered inappropriate. If there was no new prescription, documented discussion or advice to the GP to consider anti-coagulation then a decision of no discussion regarding anti-coagulation was recorded.

references

1: Wyndham CRC Atrial Fibrillation: The most common arrhythmia Texas Heart Institute Journal 2000; 27 (3): 257-2672: Barra S Providencia R Anticoagulation in atrial fibrillation Heart 2020; 107 (5)3: Sposato LA Diagnosis of atrial fibrillation after stroke and transient ischaemic attack: a systematic review and meta-analysis Lancet Neurology 2015 14 (4): 377-874: NICE NICE guideline: Stroke and transient ischaemic attack in over 16s: diagnosis and initial management 2019

results

Conclusion AND Further work

Not all patients that had atrial fibrillation diagnosed during their inpatient stay had a decision regarding anti-coagulation at the time of dischargeNew discharge documentation has been created to ensure that this is documented and communicate

Anti-coagulation discussedAnti-coagulation not discussedAtrial Fibrillation present40 (89%)5 (11%)

101 results were included in the defined study period Of the results reviewed, 52 patients had atrial fibrillation identified on their cardiac recording.Of the 52, 7 patients had known atrial fibrillation prior to admission so were excluded from the final results. Three patients that had atrial fibrillation noted on cardiac recording died during their inpatient stay. These have been included in the discussed column as a decision to not anti-coagulate had been made.

Table: 1.1:table: Total number of patients with atrial fibrillation identified with either a recorded anti-coagulation decision or no decision recorded