Streamlining Cardiac Monitoring for Atrial Fibrillation Detection in Ischemic Stroke Patients

Continuous cardiac monitoring without restricting patient mobility, leading to improved accessibility and faster AF detection rates in post-stroke patients.

Pitch Initiative:

Timely detection of AF is important for the secondary prevention of future ischemic stroke, as it may be the underlying form of stroke mechanism. With the use of anticoagulation or left atrial appendage occlusion, recurrence of AF-associated stroke can be effectively prevented.

AF is diagnosed with the electrocardiogram (ECG). However, as AF is often paroxysmal (i.e. intermittent) in nature, a snapshot ECG often misses the diagnosis. Therefore, continuous cardiac monitoring (i.e. continuous ECG) is preferred for optimal detection. Traditionally, a stroke patient is admitted to a “telemetry ward” for this purpose. Such telemetry wards are essentially cardiac wards with built-in ward hardware to continuously receive ECG device signals from individual patients. The ward-based telemetry system then performs a live transmission of received ECG data to a central terminal situated in the cardiac intensive care unit (ICU). The transmitted ECG data is continuously monitored by a cardiac ICU nurse.

The ECG device worn by the patient compromised of a box with wire leads that are placed on multiple parts of the patient’s torso. The wire leads are prone to movement artefact. In addition, such form of cardiac monitoring restricted patient activity to be within the “telemetry ward”. The ECG data transmission will be disrupted once the patient is out of the signal reception zone, e.g. when the patient goes to the rehabilitation gym or for radiology tests. Lastly, there are limited beds in the “telemetry ward” and beds are reserved primarily for cardiac patients instead, especially those with recent myocardial infarction.

Our initiative performed a root cause analysis on the pre-existing causes leading to a low accessibility and long wait time for cardiac monitoring in acute ischemic stroke. Our multi-disciplinary Heart-Brain team, comprising doctors from the cardiac and neurology departments, nurses, stroke coordinator, medical technologists and administrative personnel, identified the following root causes through a structured quality improvement process.

1) Over-ordering of telemetry service on the whole-of-hospital level, sometimes with unnecessarily long monitoring periods.

– Our cardiologist conducted teaching/educational sessions for junior doctors on the ground on appropriate indications for telemetry ordering to reduce the number of inappropriate orders. Post lecture quiz was also conducted to ensure retention of knowledge. Our cardiac operations team worked with the bed management unit to ration the telemetry beds for non-cardiac patients (inclusive of stroke patients).

2) Telemetry order is not discontinued in a timely manner even when it is no longer indicated. The initiation and termination of telemetry service require a bed transfer into and out of the cardiac discipline ward. As such, any delay in the timely termination of telemetry order chokes up the cardiac ward bed situation and causes a longer wait time for pending orders.

– In response, the neurology department’s stroke coordinator kept track of stroke patients’ telemetry orders, and regularly reminded its team doctors to terminate the order once no longer required for AF detection.

3) Limited number of cardiac monitoring capacity for non-cardiac patients

– A key feature of initiative was the implementation of a new clinical service, namely a 7-day Holter monitor (a form of continuous cardiac monitoring) via a wearable patch ECG, to complement traditional ward-based telemetry. This ECG device is worn on the chest wall as an adhesive patch. It is lightweight and showerproof, and can capture multi-channel data for precise ECG diagnosis. Due to its portable nature, a bed transfer to the cardiac ward is not needed and no ECG data is lost when the patient travels around the hospital for various clinical services. In fact, patients are allowed to be discharged from hospital while wearing the device and can return as an outpatient to return the device.

– The main difference between patch ECG device and telemetry monitoring is that the patch ECG does not provide a “live” data transmission.  ECG data is only collected at the end of the monitoring period after the device has been retrieved from the patient. For the purpose of AF detection in stroke patients, “live” data is not needed for the patients selected for the patch ECG as these are patients who do not have other serious acute conditions requiring such “live” monitoring.

With the multi-pronged approached adopted, we significantly improved the access to cardiac monitoring by allowing a much larger number of post-stroke patients to be tested upfront for AF during their inpatient stay and reduced their wait time and overall length of stay.

We improved access to inpatient cardiac monitoring by 288% from 13 cases/month (2-month average pre-intervention) to 37.5 cases/month (4-month average post-intervention). AF detection rate remained at 5% before and after intervention despite the larger denominator post-intervention. Our initiative also came with a significantly shortened wait time with a 1-day wait time rate improvement from 30.8% to 62% post-intervention.

We achieved a reduced length of stay by 1.8 days on average, along with healthcare cost savings of S$2857/patient.