Time constraints limiting uptake of atrial fibrillation screening

Morgan Liotta

13/05/2020 2:37:09 PM

One academic registrar is working towards providing better understanding and implementation of screening for the condition in general practice.

Dr Katrina Giskes
Dr Katrina Giskes highlights a need to screen more patients for atrial fibrillation to reduce preventable strokes.

It was personal experience that led general practice registrar Dr Katrina Giskes to embark on a research project to improve assessment and treatment of an often under-detected heart condition ­– atrial fibrillation (AF).
‘There is often an element of “me-search” in research, and I unfortunately lost a close family member from a stroke that was a consequence of undetected AF,’ she told newsGP.
‘This was a devastating outcome that could have been avoided if the AF was detected earlier, and appropriate treatment commenced.
‘I became involved in AF screening work in my academic term in 2019, which was a great opportunity to blend my medical and research skills.’
The research project which she is currently undertaking at the University of Notre Dame and the Heart Research Institute ­­– ‘AF TRENDS: Atrial fibrillation treatment, recommendations, electronic decision support and screening’ – earned Dr Giskes a 2019 HCF Research Foundation / RACGP Foundation Research Grant.
Dr Giskes is keen to apply her research skills in the primary care setting to develop screening opportunities and systems to detect asymptomatic AF in older adults – to help reduce the incidence of avoidable strokes.  
‘Screening for AF is simple and can easily be done by GPs,’ she said.
‘A stroke, on the other hand, is a poor warning sign of AF.’  
A heartbeat irregularity that increases the risk of stroke and heart failure, AF is becoming a growing health issue in Australia’s ageing population.
According to Dr Giskes, the detection of AF can be challenging, as many people remain asymptomatic – known as ‘silent AF’ – and the first manifestations may be a debilitating stroke or death.
Current Australian and international clinical guidelines recommend that GPs opportunistically screen for AF by pulse palpation among patients aged 65 years and older. However, Dr Giskes said research has shown that only 11% of Australian GPs follow these recommendations, with time limitations in general practice consultations the main barrier to implementing screening.
‘GPs work in a time-pressured environment, and our consults are already jam-packed with preventive health, as well as our patient’s individual issues and agendas,’ Dr Giskes said.
‘It is not a surprise then that [only a small percentage of] GPs in Australia regularly palpate their patient’s pulse. We need to be screening more of our patients than this to reduce preventable strokes.’
With a focus on taking AF screening outside of the general practice consultation time, Dr Giskes’ research is directed at implementing a self-screening station for waiting rooms that integrates within existing practice software and workflows.  
There are, however, benefits and challenges to this model.
‘The biggest benefit to patients is the avoidance of a fatal or debilitating stroke,’ she said.
‘The biggest challenge for implementing a patient self-screening station is developing [one] that will operate autonomously in the waiting room, and will not require support or directions from medical, nursing or reception staff.
‘Integrating the screening results with general practice software, so that results are automatically transferred to patients electronic medical records, has also been a challenging process and has required collaborations from several parties.’ 
Aiming for increased provision of AF education and implementation for GPs continues to be on Dr Giskes’ radar, as she enjoys the balance of clinical and research work to ‘help develop novel ways GPs can improve the health of their patients’. But some recent adjustments have been necessary.
‘Like many things, COVID-19 has put a spanner in the works for my research,’ Dr Giskes said.
‘I have had to suspend data collection in practices, mainly due to the infection risk of patients putting their hands on the screening device in the waiting room, and secondly because of telehealth there has been reduced foot traffic in practices.
‘However, we have been able to progress in the interim with some advancements in software development. Patients in rural areas are returning for face-to-face appointments faster than those in urban areas, so our patient piloting will commence in a rural area first.’
In order to support members currently impacted by the COVID-19 pandemic, the RACGP is extending application dates for the 2020 Foundation grants. More information is available on the RACGP website.
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Dr Cherry M. Evans   13/05/2020 7:05:54 PM

I find that my oximeter is a useful tool. It measures the oxygen saturation and also shows the pulse AF the pulse rate jumps all over the place in matter of minutes.auscultation of the heart with stethoscope can then confirm that the heart rate is irregularly irregular. ECG is the next step.

Dr Christopher Edward Clohesy   18/05/2020 3:39:30 PM

I can get a patient’s cardiac rhythmn and ECG trace on my phone with a cardiac App. It’s totally fantastic and it takes 60seconds. I can detect AF immediately. I can also detect plenty of other things including ST changes.

Dr Philip Ian Dawson   18/05/2020 5:35:03 PM

I cant believe there are doctors who wont take a patients pulse to detect AF, or any other abnormal rhythym, because of "time pressures"! Please put away those automatic BP machines which (a) wont give an accurate BP in AF or other abnormal Rhythyms, and (b) also will give a falsely high reading because most doctors I see using them leave the arm hanging down, rather than outstretched at chest height like I was taught to do and all hte studies on Hypertension did. The director of our local stroke unit wont let his nurses use them. Use a manual Sphygmomanometer with the stethoscope on the brachial artery ( you do remember how to do that , don't you?) and usually you will get the BP in one go (not several like the automatic machines), the patient wont complain their arm hurts after being pumped up to 200 several times, and you will easily hear the pulse is irregular. Time saved. Next step-forget the phone, do a proper ECG to properly diagnose the rhythm. use phone oximeter at home.