The future of cardiovascular care is in community pharmacy, according to senior pharmacist Zainab Khanbhai.
Zainab was recently awarded winner in the ‘Greatest Patient Impact’ category at the Annual Research Showcase held at Royal Brompton & Harefield NHS Foundation Trust, for her project looking at training community pharmacists in screening for heart rhythm problems.
But what is it all about? We delve in a little deeper into the project that aims to put community pharmacy on the map.
Zainab is a senior cardiothoracic surgical pharmacist with a special interest in atrial fibrillation, providing a clinical pharmacy service to patients admitted for cardiac and thoracic surgery.
Her day to day routine involves attending surgical and antimicrobial ward rounds, working closely with the multi-disciplinary team to ensure medication is safe and appropriate.
So how did she become involved in a project which trains community pharmacists to diagnose heart rhythm problems?
“The idea for the project originated from Dr Wajid Hussain, a cardiologist here at Harefield Hospital, and Sally Manning, a former senior pharmacist, who wanted to find a way to diagnose people with otherwise undiagnosed atrial fibrillation (irregular heart beat). They thought that by training community pharmacists to diagnose the condition using a small hand-held heart monitor, people who might otherwise go undiagnosed for years, could be diagnosed and treated earlier, preventing future complications.” Says Zainab.
What is atrial fibrillation (AF)?
According to the British Heart Foundation, AF is a condition where the hearts normal rhythm is disrupted, affecting how it pumps blood around the body.
“The heart’s pumping action is controlled by tiny electrical messages produced by a part of the heart called the sinus node. Now, in a healthy heart the electrical signals are sent out regularly, with each signal telling the heart to contract and pump blood around the body.
“AF happens when, as well as the sinus node sending out regular electrical impulses, different places in and around the heart also produce electrical messages, in an uncoordinated way. These multiple, irregular messages make the upper chambers of the heart, quiver or twitch, which is known as fibrillation and is felt as an irregular and sometimes fast heartbeat, or pulse.” Zainab explains.
What happens if someone is left undiagnosed?
AF can present in some people as mild symptoms, including palpitations, tiredness, shortness of breath, dizziness and/or feeling faint. But in some people, there are no symptoms at all, leaving many remaining undiagnosed for years.
If left undiagnosed AF can increase the risk of a blood clot forming inside the heart. If the clot travels to the brain, it can lead to a stroke with AF increasing the risk of stroke by around four to five times.
However, with appropriate treatment the risk of stroke can be substantially reduced. Anticoagulants (blood thinning) drugs and a newer class of blood thinning drugs called DOACs (Direct Oral Anticoagulants) can be used to reduce the risk of stroke in people with AF.
Which makes early diagnosis extremely important.
How it all began
In 2015, an application was made by Dr Hussain and Sally Manning to the Health Foundation to fund a small-scale screening program in community pharmacies to help improve detection and treatment of AF, with the ultimate aim of preventing stroke. Zainab joined the team a few months later to help lead the service.
They were awarded £75,000 for the project which helped to train 10 community pharmacists in the Hillingdon area and to determine whether handheld ECG monitors (Kardia®), which are cheap, mobile devices that require no attachments, could be used to help diagnose the condition.
The training for the community pharmacists meant that they could identify patients with a previous diagnosis of AF or with risk factors for AF, and would involve;
- A face to face consultation where the pharmacist measures the patient’s heart rate and rhythm using the Kardia® monitor
- Assessment of the patient’s risk of stroke and symptoms using a questionnaire
- Reviewing patients who are given anticoagulation medication
Any patients who were deemed as at risk of AF were then referred directly to the Arrhythmia Care Team (ACT) at Harefield Hospital for management.
The small-scale study proved a success with 591 patients screened, 90 patients referred to the Trust and a total of 28 patients seen by the ACT. Of these patients, 10 were newly diagnosed with AF and another five patients, already with a diagnosis of AF, were started on medication.
More funding and project expansion
Although the results from the pilot study proved the process was cost effective and could work on a small scale, the team needed to demonstrate the same benefits for a larger population of patients.
In 2017, Zainab Khanbhai and Dr Hussain led a grant application to the Academic Health Science Network (AHSN) in collaboration with BMS-Pfizer Alliance. They were awarded £100,000 which allowed them to train up to 30 new community pharmacists in the Hillingdon area, leading to over 1300 patients being screened.
208 patients were referred to the ACT, with 76 patients seen in clinic. The study saw a further 16 patients newly diagnosed with AF, and two patients with previously diagnosed AF were started on medication.
One important outcome from the study was the time it took from diagnosis of AF to referral for treatment. In this study 60-70% of all patients who were diagnosed with AF by the community pharmacists were seen at clinic at Harefield Hospital within 2 weeks.
The project was so successful that in 2019 when the team applied for more funding from AHSN/BMS-Pfizer, they were awarded a further £93,000.
This project, which is currently underway, aims to expand the referral service from it being at just Harefield Hospital to GP practices. The funding will allow Zainab, in her role as a specialist pharmacist, to see patients at a GP surgery in Hillingdon.
For patients this would mean being seen at a GP practice rather than travelling to Harefield Hospital’s arrhythmia clinic.
Zainab says this is all part of the NHS Long Term Plan to have more specialist services integrated within the community, providing care closer to home.
“This is an exciting new development, allowing further integration with primary care. The NHS long term plan has set out initiatives for prevention and treatment of cardiovascular diseases and suggests areas where pharmacists can become involved.
“This project, which builds on the existing work we’ve already undertaken and the expansion of this project into primary care, not only embeds this service further but creates an opportunity to align perfectly with the initiatives of the NHS long term plan. This service is unique because it creates a purely primary care based service that is integrated with a specialist secondary care team.” Zainab explains.
If the project proves successful at this scale, Zainab and the team will need to show evidence that the process is cost effective, which is why they are now collaborating with a health economist, whose job it will be to determine if the project has value for money for the NHS.
“We’ve already demonstrated that this service is cost effective on a small scale and we now need to demonstrate this on a wider scale. We know the NHS doesn’t have a finite amount of resources, so it’s important for us to demonstrate that it cost effective to diagnose patients with AF earlier, thereby preventing the more serious complications that arise from undiagnosed AF, such as stroke.”
The team are also working closely with commissioning managers to look at how the project can be expanded across the NHS.
So, what does this all mean for the diagnosis of AF in the future? Will we all be able to get screened at our local pharmacy?
Zainab remains optimistic; “Yes. We’re confident that from these positive study results, the health economist can demonstrate cost savings to the NHS and therefore make it easier to convince the commissioning groups.”
Results from the study are expected to be published in the coming months.