Actioning atrial fibrillation identified by ambulance services in England: a qualitative exploration

‘Paramedics are already doing it’

All participant groups were generally in favour of formalising the response to incidental identification of AF by paramedics. It was considered a simple intervention with the potential to reduce the risk of longer-term problems for patients, save money for the NHS in the future, complement primary care detection efforts and reduce the burden on urgent care. P reported that ECGs are recorded for most patients in the emergency setting, including those who are not transferred to the hospital. AF was considered the most common ECG abnormality they found, being encountered multiple times on a shift. Though broad screening was not advocated by any participant group, public participants felt that it made sense for paramedics to look for and report incidental findings of AF since they were already doing an ECG as part of their routine patient assessment. Experts too recognised, that informally, paramedics are already doing opportunistic screening:

‘I think it is a good idea, because if you are coming out to see somebody in the community and you are doing this as part and parcel of it, its just another check you can do.’ (FG2)

‘Within the service… [identifying AF] is something that we do on an informal basis at the moment.’ (P9)

‘I suspect they’re doing a lot of it already anyway.’ (FE1)

‘There is a responsibility to act’

Paramedics held a strong sense of responsibility for the patient and shared a reluctance to leave patients in the community without some form of active handover. One paramedic reported that they would always transport patients with newly identified AF to the hospital for investigation even if they were asymptomatic, believing this to be Trust policy and that it is better to err on the side of caution. Others tended to contact the patient’s GP directly and additionally complete a ‘leaving at home’ report, usually including a copy of the ECG. For patients who were not transferred to the hospital, the routine ECG was considered especially important by paramedics to ensure both patient safety and defensible clinical practice:

‘I don’t think we would ever leave someone with a newly found AF at home without at least ringing the GP and letting them know.’ (P9)

‘I tend to do an ECG as a belt and braces for leaving them at home to kind of protect my registration and to dot the i’s and cross the t’s.’ (P8)

Notwithstanding cautions about unnecessary EMS burden, making sure incidental findings acted on were considered by experts to be in keeping with the NHS ‘making every contact count’ strategy,24 and had potential to improve patient outcomes. Public and expert participants agreed that if an abnormality is picked up, then there is a responsibility to do something about it:

‘I think we are all singing from the same hymn book really, we’re all in agreement here … if an ambulance comes out and they know someone’s in AF, it would be criminal to ignore it … something should be done, obviously’ (FG4)

‘Everybody would say ‘well you’ve identified a potential problem, you should do something about it’ and therefore since paramedics are doing tests that could identify accurately the presence of AF I believe that, if it is so identified, it should be reported, so that people can deal with it.’ (FE4)

‘I think at the end of it all you’re down to the fact that if something is being picked up then there is a responsibility to do something about it and it’s what’s the right thing to do about it is what this research is fundamentally looking at.’ (FE1)

‘Communicating a new diagnosis of AF: Current reporting methods are insufficient’

On detecting an anomaly—incidentally or opportunistically—knowing what is the ‘right thing to do about it’ is currently a missing link for paramedics. Paramedics were not aware of guidance or a pathway for managing newly identified AF, particularly for patients who are to remain in the community rather than be conveyed to the hospital. Establishing whether AF is pre-existing can be difficult as patient awareness of their AF is sometimes limited, and while their summary care record may be accessible for evidence of an existing diagnosis and any prescribed medication (eg, OAC), these data are not always available, and are often incomplete. Both paramedics and field experts considered that the current electronic clinical report was an insufficient method for alerting GPs to new AF as it may be buried in a lengthy report and subsequently missed by the GP resulting in a lack of follow-up. To address this concern, experts proposed that a new diagnosis was prominently flagged in the ambulance documentation that is shared with the GP, potentially with the ECG digitally attached. Beyond this simple intervention, there was no consensus on whether a new care pathway was needed. Parallels were drawn from the likely detection of other new findings such as raised blood sugars and raised blood pressure, and where there may be transferable learning. Public participants also suggested more prominent and direct flagging of an incidental diagnosis of AF to the GP, but there is currently no facility in the system to do this. There was broad support for formalising the process for informing GPs of new diagnoses of AF:

‘I would hope that for these incidental findings and the patients who don’t go to hospital, that we had an established pathway … then I’d be happy that the patient can be more safely left in the community with an immediate follow up plan.’ (P5)

‘I would definitely flag it up to the GP surgery (and) not only put it in a medical record, because they, very often, could just not be seen. They are very busy.’ (FG2)

‘When there’s actions for the GP on the communication … it must be barn door at the top of the letter ‘The following letter contains actions for the GP’. It can’t be an afterthought, or on paragraph 5.’ (FE2)

‘Opportunistic screening for AF must not create delays for EMS’

Despite broad support for formalising opportunistic screening, public and expert participants expressed a strong concern that this could take time for a busy workforce and was considered a secondary role for EMS. It was recognised by paramedics and experts that EMS managers would also need to be reassured that formalising the process would not create delays in the system. Both participant groups were clear that any change to current practice should not increase EMS time on scene and suggested that adapting existing systems was preferable:

‘They are an emergency service … they’re not a mobile diagnostics service, so you know, could someone else possibly be dying while they were involved with a patient they don’t think needs to go to hospital but have discovered they have AF?’ (FG4)

‘‘It needs to not create extra work for ambulances, and not create any delays … it absolutely can’t take them any longer… you’re far better adapting a current line of communication rather than doing something new.’ (FE3)

Reflecting on this concern, field experts estimated that relatively few people with new or untreated asymptomatic AF would be identified by paramedics, and that there could be overlap with existing community-based AF identification initiatives. Some questioned whether current processes for reporting incidental findings of AF were sufficient, and additionally expressed caution about progression from actioning an incidental finding towards a programme of opportunistic screening for AF by paramedics. Paramedics reported that a formalised pathway for notifying GPs would not increase their workload, since many are doing this already. It was further suggested that a formalised pathway may ‘empower’ some paramedics to engage with opportunistic identification of AF more confidently, particularly in people who engage infrequently with healthcare services:

‘We’re seeing people that maybe haven’t seen a GP in a long time or they’re not engaging with healthcare as they should… they might not get another opportunity to have an ECG or they might not consent to another opportunity.’ (P8)

Paramedics further reported that in most cases there is a known history of AF, and identifying a new diagnosis of asymptomatic AF was uncommon.

‘Communicating a new diagnosis of AF: How best to inform the patient?’

Discussion about communicating the finding of AF to the patient dominated discussion in each FG. Public participants across the four FGs unanimously agreed that the patient had a right to know and should be told about the finding of AF, but they were divided on when and how this should be done and by whom. Those in favour of paramedics telling the patient ‘there and then’ felt that an informed patient may expedite follow-up, whereas not telling them may lead them to disregard future symptoms. While concerns were also driven by a desire not to delay paramedics unnecessarily, those opposed felt that the finding should ‘go back to the GP’ to act on to avoid additional anxiety and distress to the patient, especially since AF is a non-urgent, non-life-threatening issue, that may or may not benefit from intervention. Ultimately, since no compromise in position was reached, the general consensus was for consistency in approach:

‘I don’t think it can be expected of ambulance crews to make a judgment on who is told and who isn’t told, so I think they should have a blanket approach to it, either they are going to tell the patient anything that they find or they’re going to withhold it and flag it up for the doctor.’ (FG3)

If information is to be shared by paramedics, there was consensus that this should aim to minimise anxiety while also motivating the patient to seek follow-up, and perhaps include written information and a copy of the ECG. Public participants also agreed that discussion of risk and treatment would be unnecessary as paramedics would not be treating incidental AF in the emergency setting. Since findings from hospital-based tests are routinely fed back to GPs, this was familiar and acceptable.

‘Getting the diagnosis right’

With the patient’s well-being at the forefront, further reassurances sought by some public participants included that EMS was trained in AF identification and had sufficient experience in communicating new diagnoses with patients. Paramedics did not feel specific training was necessary as competence in making a diagnosis of AF was considered routine. However, refresher training may be useful for some to address any insecurities or reluctance to do so, and decision criteria would provide support to paramedics on scene:

‘I would be really surprised if it actually is a topic that we would need to train paramedics to identify rhythm … a rhythm diagnosis is very bread and butter for paramedics so I think that there shouldn’t be any skills training. It would be about reducing the barriers for people to have these diagnosis discussions, and there might be a case for that. So it would all be soft skills rather than hands on skills.’ (P7)

Having a brief explanation in the form of a leaflet or mobile phone quick-response (QR) code was proposed to aid patient communication by all participant groups and generally considered sufficient information for the patient at the point of EMS contact. Field experts additionally considered the potential personal implications of receiving a diagnosis of AF such as self-perception, changes in behaviour and impacts on life insurance and travel insurance. Getting the diagnosis right was therefore imperative, and they suggested that the diagnosis made by the paramedic is not necessarily the definitive diagnosis:

‘So that’s the first clinical question […] am I (as a GP) confident that I can make that diagnosis of AF from this information, this ECG or not […] to put AF on to this person’s medical record, to stick with them for the rest of their life as a as a lifelong diagnosis, potentially expose them to the risks of anticoagulation, change their life insurance risk, etc? Because if the answer is ‘yes, I am’, then it’s one pathway. If the answer is ‘no, I’m not […] then it’s another pathway about repeating the ECG, getting the diagnosis right first.’ (FE5)