Keenan Saleh, Jasjit Syan, Pavidra Sivanandarajah, Michael Wright, Sarah Pearse, Jodian Barrett, James Bird,Grant McQueen, Sadia Khan
Abstract
Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia and poses a significant public health burden. Virtual wards are a novel approach utilising digital solutions to provide hospital-level care remotely; their rollout has become a key priority for the UK National Health Service to expand acute care capacity. We devised and implemented a digitally-enabled AF virtual ward to monitor patients being established onto medical therapy following an AF diagnosis or an AF-related hospitalisation. Patients were onboarded either as outpatients to avoid admission or on discharge after an acute AF hospitalisation. Remote monitoring was undertaken using a clinically validated photoplethysmography-based smartphone app. Over a 1–2 week period, patients performed twice daily measurements of heart rate and rhythm and provided corresponding symptoms.
Introduction
Atrial fibrillation (AF) is the most common cardiac arrhythmia in the UK. Public Health England estimates that ~1,300,000 people are living with AF in the UK [1] and projections indicate that this could reach as high as 1,850,000 by 2060 [2]. Treatment is targeted towards the prevention of AF-related complications, such as heart failure and stroke, and the improvement of symptoms and quality of life. Timely evaluation is key to ensure that oral anticoagulation is promptly commenced in high-risk patients, as well as to initiate and assess response to pharmacological therapies.
Materials and method
We initially undertook a retrospective analysis of AF presentations to our emergency department, from March 2022 – September 2022. Our results suggested that a significant proportion of patients could be more optimally managed in an outpatient setting with remote monitoring to reduce length of stay, improve flow through the hospital and produce potential cost savings with reduced bed occupancy. We therefore developed and implemented an AF virtual ward across 2 North West London hospital sites (West Middlesex Hospital and Chelsea & Westminster Hospital). This work was approved by NHS North West London and the trust’s governance processes for service improvement and innovation and hence formal ethical approval was not sought.
Results
We initially undertook a retrospective analysis of AF presentations to our emergency department over the 6-month period preceding implementation of the AF virtual ward (March 2022 – September 2022). We determined that the mean length of stay of hospitalised AF patients was 7 days. Patient turnaround was influenced by several factors, including inadequacy of rate control, patients awaiting further inpatient tests or treatments, concomitant medical conditions requiring ongoing acute care and social concerns.
Discussion
In this study, we share our early experiences of the implementation of an AF virtual ward to remotely monitor patients being established on treatment following an acute presentation. This intervention facilitated the early detection of health deterioration in 9 of the 73 patients, resulting in appropriate recommendations to seek urgent medical attention or call emergency care services. Over a longer 3-month time span following completion of remote monitoring, only 3 patients re-attended with an arrhythmia-related presentation, and a clear cause can be isolated in each case.
Conclusion
In this study, we present a novel AF virtual ward model, which can be implemented at relatively low cost and with wider accessibility using smartphone-enabled remote monitoring via a centralised monitoring hub. Our findings indicate that our virtual ward model enabled patients to be effectively triaged remotely, allowed health deteriorations to be recognised early, ensuring patients received timely medical attention or emergency care, and reduced the likelihood of subsequent ED reattendances on discharge. We also demonstrate the potential cost effectiveness of our model through readmission avoidance and early supported discharge of stable hospitalised AF patients, who might otherwise have had a longer inpatient stay.
Citation: Saleh K, Syan J, Sivanandarajah P, Wright M, Pearse S, Barrett J, et al. (2024) Insights from a single centre implementation of a digitally-enabled atrial fibrillation virtual ward. PLOS Digit Health 3(3): e0000475. https://doi.org/10.1371/journal.pdig.0000475
Editor: Jennifer N. Avari Silva, Washington University in Saint Louis, UNITED STATES
Received: September 21, 2023; Accepted: February 17, 2024; Published: March 20, 2024
Copyright: © 2024 Saleh et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: The anonymised data are provided and accessible within the supplementary information.
Funding: The trial of the FibriCheck application and digital integrations for this project were developed with funding from the CW+ charity as part of their innovation programme (Award 0179, recipients: SK & MW). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Source: https://journals.plos.org/digitalhealth/article?id=10.1371/journal.pdig.0000475#sec017
