Y&H AHSN Stroke Prevention Atrial Fibrillation

Expression of Interest Form

AliveCor Kardia/ WatchBP device to detect Atrial Fibrillation

How to get involved

If you would like to participate please complete and return this expression of interest form by email to:

Provider Details
CCG
GP Practice Code
GP Practice Name
GP Practice Address for Delivery of Devices
Practice Manager or Administrator
Name & Email Address
Direct Dial Telephone Number
Designation of professional groups requesting to use the devices.
eg specialist nurses, podiatrists, pharmacists, GPs, paramedics etc
Contact details for your clinical champion who will take the lead for implementing the AliveCor Kardia/ WatchBP device within your practice. / Name
Job Title
Email*
Tel No
Type YES in this box if you are willing for Y&H AHSN to share your email address with the manufacturers of AliveCor Kardia or WatchBP. This will support the national evaluation of these devices.

* Y&H AHSN will keep this information file for audit and evaluation purposes and may contact you in the future.

Number of AliveCor Kardia/ Watch BP Devices Requested
Does your GP practice have any mobile ECG devices already? (eg Kardia, WatchBP, MyDiagnostick) / YES/NO
If YES, please state how many?
How many branch surgeries do you have?
How many AliveCor/ WatchBP devices does your GP practice require initially? / AliveCor Kardia
WatchBP
To use the AliveCor Kardia device it has to be used with an android phone, tablet, iPhone, iPod or iPad tablet. These devices are not supplied by Y&H AHSN. A list of compatible Apple & Android phones and tablets is available via this link:

What we expect from you: Practice commitment to use of devices to improve diagnosis of AF
Is the potential mobile ECG device user willing to agree to the following? / YES / NO
Adhere to the guidance on safe use, cleaning & hygiene
Adhere to local Information Governance policies
Use Life QI on-line system to record your data
And if using AliveCor Kardia
Obtainconsent from patients (if using) that their trace will be anonymously sent to AliveCor and will be stored on the company’s servers.
Email files using nhs.net address and then identify file for uploading to clinical system
Download the Kardia app (basic version)
Agreement:
By returning this form I agree that I will comply with all of the above terms and conditions in order to participate in this project. I understand that Y&H AHSN hold no responsibility for the use or maintenance of the devices provided.
Name
Job Title
Organisation
Date

Yorkshire and Humber Partners Academic Health Science Network Ltd

Unit 12 Navigation Court, Calder Park, Wakefield WF2 7BJ

Tel +44 (0) 1924 664710

Company Registration No: 8887451 England │VAT Registration No: 183 5404 08