124/A quality improvement project to improve the diagnostic pathway for patients referred to cardiology with palpitations

Introduction: Many referrals to cardiology outpatient clinics are for patients with palpitations. Patients can wait several months before their first appointment. Diagnosis, often dependent on symptom and ECG rhythm correlation, is further delayed due to the need to perform and review investigations. This results in delayed treatment and anxiety for many patients. Smartphone and wearable ECG devices are available to both patients and clinicians at a relatively low cost. They allow patients to record a single lead ECG at the time of symptoms and email them for interpretation. Several studies have shown their use in diagnosing arrhythmias.
Methods: We identified all patients seen in the arrhythmia clinic with palpitations over a one-month period (October 2016). Audit data was collected to assess the patient pathway, including number of follow-up appointments and time to diagnosis. Following this, we implemented the quality improvement project (QIP).
Prior to their first clinic appointment, suitable patients were given an AliveCor Kardia Mobile device to record an ECG whenever they experienced symptoms. Patients emailed their ECG along with a description of symptoms to the QIP team. These were given to the cardiologist when the patient attended their first clinic appointment. Patients were given a questionnaire to assess how easy they found using the device and the likelihood of them recommending to friends
and purchasing the device.
Results: From our retrospective audit of all outpatients reviewed in our arrhythmia clinics during the month of October 2016, there were 22 new patients referred for diagnostic assessment of palpitations. The mean time from referral to diagnosis was 189 days. 13/22 patients (59.1%) were discharged at their first clinic visit.
In our ongoing QIP, the AliveCor device has been used in 16 patients so far. The mean time from referral to formal diagnosis reduced to 115 days. 12/16 (75%) patients were discharged at their first clinic visit, reducing the need for follow-up. The rhythms detected include sinus rhythm, sinus tachycardia, ectopic beats and atrial fibrillation.
The average ‘ease of use’ score was 8.92/10. 92.31% of patients would recommend the device to a friend. 53.85% of the patients overtly stated that they would purchase the device themselves. Of the five patients who had also undergone Holter monitoring and two patients who had undergone memo recordings, 100% described the Alivecor as being ‘much easier’ and ‘much more convenient’ to use than other devices.
Conclusion: Our preliminary data suggests that smartphone ECGs can provide symptom-rhythm correlation, provide a greater diagnostic yield than conventional investigations and reduce time to diagnosis. Qualitative feedback from patients shows that the device is very easy to use and an acceptable method of investigation. Our QIP demonstrates a novel way of implementing these devices into patient pathways. Further work is needed to look at extending this into primary care.