The Cardiovascular Ambassador Project involves 20 participating health services and hospitals, including Northern Health, to improve the quality of cardiac care delivered to patients, and reduce unplanned hospital readmissions.

Participating hospitals have received funding by Safer Care Victoria for a cardiovascular liaison nurse to plan, lead, implement and coordinate appropriate multifaceted interventions for each site’s model of care. The model of care for this project in 2023 is focusing on atrial fibrillation.

Atrial fibrillation is the most common cardiac arrythmia and contributes to significant burden upon Victorians as the leading cause of stroke and a frequent cause of hospital admission.
Northern Health currently receives 400-500 admissions for this cohort of patients annually, with an unplanned readmission risk of 16 per cent in the last year.

The Rapid Access Atrial Fibrillation (RAAF) clinic is a face-to-face nurse-led clinic that focuses on supporting patients and implementing evidence-based care for patients who have been recently admitted with atrial fibrillation/flutter, or where atrial fibrillation has been a major clinical event during their inpatient stay.

The aim of the RAAF clinic is to ensure that decisions regarding rhythm and rate control are made in a timely manner, appropriate prescription of anticoagulation, better symptom control and to help support the patient’s stability in the initial vulnerable phase following discharge.

The clinic is led by Madonna Goro, Cardiac Liaison Nurse/ Atrial Fibrillation Clinical Nurse Consultant and Rob Clayton, Cardiac Nurse Practitioner, with medical oversight by A/Prof Gautam Vaddadi.

There will be a strong focus on managing comorbidities that drive atrial fibrillation, such as weight management, obstructive sleep apnoea and alcohol use.

Wait times for patients to be seen by an electrophysiologist at Northern Health is currently a nine – 12 month wait. The RAAF clinic is one-stop shop that will aim to review these patients within two weeks post discharge and ensure a thorough management plan and appropriate follow up is established. This will help to alleviate some of the burden on the Outpatient’s clinic department and improve patient outcomes and satisfaction.

“There is well-established clinical research to support and prove nurse-led integrated atrial fibrillation clinics to reduce all-cause mortality and improve patient outcomes,” said Ms Goro.

The RAAF clinic launched on 27 March 2023 and is a weekly clinic that runs on Monday afternoons, with a 30-day telephone follow up clinic to assess patient progress and evaluate outcomes.

All patients reviewed in clinic thus far have reported positive feedback and appreciate the prompt follow up. Please see below recent patient feedback:

“The help and management and being able to touch base with someone has been amazing.”

“I felt so reassured by you, Madonna. You and Rob listened to me and adjusted my medications, and I feel so much better than I ever have. You have taken the fear out of it, and I know I have someone to touch base with when I am unsure.”

“Having that rapport with someone is valuable. I am so grateful I got to meet you in hospital and be seen in the rapid access AF clinic when I did, and I believe it has kept me out of hospital.”

If the pilot project proves successful, the plan is to increase clinic sessions and open up referrals to Outpatients and general practitioners within the local community.

“By raising awareness of this cardiac condition, we hope to equip and empower patients to self-manage their condition and keep them well in the community,” said Ms Goro.

Pictured : A/Prof Gautam Vaddadi, Madonna Goro, Cardiac Liaison Nurse/ Atrial Fibrillation Clinical Nurse Consultant and Rob Clayton, Cardiac Nurse Practitioner.