I became a registered nurse in 1993 and, 18 months after qualifying, I pursued a career in cardiology, which led me to undertake a variety of roles, including ward staff nurse and specialist nurse. As a ward nurse, I was able to cultivate leadership, education and patient advocate skills, developing a passion for patient education, in particular for patients with arrhythmia, which has stayed with me throughout my career.
While working as a cardiac rehabilitation nurse, I was fortunate to be able to set up a unique research-based cardiac rehabilitation programme for patients with an implantable cardioverter defibrillator (ICD). This service provided patient support, education and an opportunity to exercise within a safe environment. From this initiative, ICD patients continue to have access to a research-based, ICD-specific, rehabilitation programme, thus improving the patients' physical and psychological health.
I had the opportunity to attend national meetings and conferences where I networked with other nurse specialists who were providing care for arrhythmia patients and we founded a supportive arrhythmia nurse forum. The National Service Framework (NSF) for Coronary Heart Disease, which included arrhythmias and sudden cardiac death was published in 2005 (Department of Health Coronary Heart Disease Team, 2005), leading to an expansion of arrhythmia nurse specialists across the UK, many of whom were funded by the British Heart Foundation.
A comprehensive service
Within my own hospital the NSF enabled me to develop the role of Cardiac Rhythm Nurse Specialist, and reconfigure existing services under one umbrella, forming a comprehensive service for patients, run by a skilled specialist nurse team. This included the cardioversion service, preadmission for cardiac devices and patients undergoing ablation procedures. Patients are given access to education about their condition and procedure, alongside the required psychological support that leads to informed consent. I was able to develop and implement a training package for delegated consent by the specialist nurse team, to be undertaken at the time of preadmission.
Service developments
Throughout this process, I developed a passion and drive for service development to improve patient pathways, ensuring patients were always the primary focus. I have had the opportunity to present this work locally, nationally and internationally, working with secondary care, primary care and industry colleagues. As the service has grown, I have continued to develop my clinical skills and undertook an MSc in advanced practice and implemented a nurse-led follow-up clinic for patients post ablation.
With the support of my consultant colleagues, I developed skills in assessing new patient referrals and we established a rapid access atrial fibrillation (AF) clinic, a primary care pathway for admission avoidance for GPs to refer AF patients. Patients undergo timely assessment of their condition, which includes an echocardiogram, 12-lead ECG and individualised holistic management plan, including prescribing anticoagulation to reduce the risk of stroke, symptom management and referral for potential procedures.
Advanced practice
In 2016, I became an Advanced Clinical Practitioner (ACP). Using my extensive knowledge and experience in arrhythmia, I continued to evaluate the patients' pathways and identify potential improvements. There was a national move to train allied health professionals to undertake extended roles commonly associated with medical staff. Facilitated by a comprehensive period of training and clinical supervision, I was then able to work as an independent operator implanting implantable loop recorders (ILRs). Patients were experiencing prolonged waiting times and following this initiative, the waiting time reduced from 13 to 4 weeks, and infection rates declined. We also provided same-day implants for the syncope service. Since the start of the service, I have been instrumental in undertaking the training of medical and other allied health professionals in implanting ILRs. More recently, I have been trained to explant loop recorders that are at the end of their battery life, again reducing waiting times and, by undertaking both procedures, medical time has been released to undertake more complex procedures.
Having had experience within the cardioversion service previously, there was a natural progression with the ACP role to perform cardioversion procedures when medical cover was unavailable. A change in the service has led to sedation being administered by physician assistants in anaesthesia. Consequently, the procedures are often non-medically led; the service has flexibility, which has reduced the number of patient cancellations. Each of the service improvements that have been implemented has been well received by patients, who are grateful for the opportunity to discuss their condition and receive support when needed.
COVID-19 was challenging for NHS staff and service delivery. Services have been revamped in ways we didn't think were possible. It is through this that my greatest challenge and most rewarding opportunity has been created. The pathway for patients who were admitted to hospital acutely with a primary diagnosis of AF, and who had a fast heart rate but were otherwise stable, required review. These otherwise ‘well’ patients were cared for on a ward where they were attached to a heart monitor while medication was adjusted to reduce their heart rate. They could then be discharged home. AF is the most common cardiac arrhythmia in clinical practice, with AF-related hospital admissions driving the main cost and capacity burden. An 8-week retrospective audit demonstrated that 50% of patients presenting to our admissions unit met this criteria.
A virtual ward
Technological advances and the development of digital monitoring have provided a new approach to deliver patient care through telemedicine. The novel AF virtual ward concept was developed by Professor André Ng, Consultant Cardiologist/Electrophysiologist at the Trust and Dr Ahmed Kotb, Clinical Research Fellow in Cardiology at the University of Leicester. Together, we developed this model further and were successful in obtaining local funding to undertake a proof-of-concept pilot study. My drive and passion were instrumental in the development of an AF virtual ward, and enabled us to turn the concept into a functioning ward after just 6 weeks.
There were challenges in cutting through the red tape, working with colleagues in IT and information governance and digital partners to complete the required documentation to meet the NHS standards and be able to provide hospital-level care for patients in their homes. Patients are given a blood pressure monitor, single-lead ECG device, and a pulse oximeter. They send through readings via their smartphone or tablet to an electronic platform. Results are reviewed at least twice a day, 7 days a week on virtual ward rounds by either a specialist arrhythmia ACP or cardiology registrar. Patients are discharged once their heart rate is controlled by medication or their rhythm has reverted back to normal. A specialist electrophysiology follow-up is arranged, along with a comprehensive management plan.
On the virtual ward, patients are supported remotely via messaging through the digital platform, telephone or video consultations. Support incorporates health education, lifestyle advice, medication adjustments, and other clinical decisions. During their stay on the virtual ward, the patients' long-term plan is reviewed and many are referred directly for cardioversion or ablation, preventing a long wait for outpatient appointments. We were successful with this novel concept in securing funding from a Digital Healthcare Partnership Award. This enabled the recruitment of two new ACPs and further monitoring equipment, allowing the service to grow, along with a grant from the Academic Health Sciences Network to support a formal evaluation of the new patient pathway. Since starting the virtual AF ward, we have treated more than 275 patients from both outpatient and inpatient settings, reducing patients' length of stay and preventing hospital admissions.
We have found that patients feel empowered in their care and bed use has been improved within the Trust. Delivering the service has been challenging and has pushed the boundaries of care provision at times due to patients' high clinical acuity. However, the service has been delivered safely with minimal need for readmissions and positive patient satisfaction, with a 100% score on the Friends and Family Test. The service facilitates a collaborative clinician–patient relationship, which continues post discharge in their treatment journey. I feel very proud to have played a significant role in the implementation, development and continuing care provision of this service.
We have had the opportunity to present on the AF virtual ward on numerous occasions nationally and internationally at the European Society of Cardiology and European Heart Rhythm Association conferences and were also invited to present to the Shadow Health and Social Care Secretary as well as the Chief Technology Officer, NHS England and NHS Digital. It was also encouraging to have been recognised with an AF Healthcare Pioneers Award from the AF Association and to collect the accolade at the Palace of Westminster. We were also the winner in the recent Health Service Journal 2023 Awards in Acute Sector Innovation.
Patients at the centre
Throughout the years of service development I have been conscious to ensure patients and my colleagues are integral to the change process at every step. I am privileged to work alongside supportive medical and nursing colleagues who have enabled me to push boundaries in the pursuit of improving patient care. It has been their kindness and recognition of my work that led to my surprise nomination for this BJN Award, and to them I am truly grateful. With their ongoing support we will continue to develop and adapt our services to meet patients' needs aimed at better patient outcomes and experiences. Consequently, it is hoped that this would ensure we meet the demands of an increasing population and that healthcare services are sustainable in the long term.