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Improving and Standardizing Care of Patients with Atrial Fibrillation in a Community Emergency Department

Bekki Hess, MD; Kara LeClerc, MD; Susanne DeMeester, MD

Bekki Hess, MD Kara LeClerc MD Susanne DeMeester, MD
Atrial fibrillation affects 3 million people in the United States each year and roughly one in four patients will develop atrial fibrillation (AF) or atrial flutter (AFL) during their lifetime.1 Most patients that present to the Emergency Department with AF or AFL are admitted to the hospital, accounting for much of healthcare expenditure associated with this condition. The annual cost for treatment of atrial fibrillation has been estimated at $6.65 billion, with up to 73% of that being attributable to inpatient hospitalizations.2,3

Despite the prevalence of this arrhythmia, there is substantial variation regarding how these patients are managed once presenting to the ED, and no consensus guidelines exist which identify patients who require admission versus those who may be treated on an outpatient basis.4-7 Even the most recent guidelines from the American Heart Association and American College of Cardiology fail to describe ideal candidates for safe discharge home.8 Often patients are treated with intravenous medications, undergo advanced imaging, have urgent cardiology consultation, and are admitted to the hospital when AF is rarely an immediately life threatening condition. The exceptions to this are in cases of concomitant hemodynamic instability, acute heart failure, acute coronary syndrome, or syncope.

At Saint Joseph Mercy Hospital in Ann Arbor, Michigan, a community hospital with an 80,000 annual ED visits, we established an algorithm to identify patients requiring admission to the hospital from the ED, and to treat and discharge patients suitable for outpatient management. Our goal was to safely decrease unnecessary hospitalization for patients presenting to the ED with AF or AFL.

Patients who presented to the ED with recent-onset atrial fibrillation or flutter, if they did not have any high-risk features requiring admission, were generally treated with lenient rate control (< 110 bpm), though cardioversion was considered in appropriate patients. Cardiologists were not routinely consulted and did not evaluate patients in the ED, but did guarantee follow up appointments for patients in an AFib Clinic in 2-3 business days. Anticoagulation and advanced imaging was generally deferred until this follow-up visit. Patients discharged from the ED received prescriptions for rate controlling agents, as well as educational pamphlets and pocket cards outlining their diagnosis and indications for ED return.

Our study period ran from March 2015 to March 2016 and consisted of 516 patients; it was compared to a similar baseline cohort of 581 patients from March 2013-March 2014. The overall admission rate dropped from 80.2% (466/581) to 66.9% (345/516), accounting for an absolute reduction in admissions of 13.3% (p value < 0.001). When specifically looking at lower acuity patients (identified by a hospital-wide illness severity score), the number of patients admitted decreased from 63.5% (160/232) to 43% (92/214), with an absolute reduction of 20.5% (p value < 0.001).

To examine the issue of patient safety regarding outpatient management, we used the surrogate measures of ED return visits within 3 and 30 days. Despite the marked decrease in the admission rate, there was not an observed increase in ED return rates. The rate of patients returning to ED for any reason within 3 days of the index ED visit was stable at 1.2% (March 2013-March 2014) and 1.0% (March 2015-March 2016) with a p value of 0.993. Thirty day ED returns were also stable at 3.6% before algorithm implementation compared to 3.7% afterwards (p value 0.999).

88.5% of patients referred to the Clinic were seen in the following 3 business days. All the remaining patients were contacted by telephone and did not follow up in the AFib Clinic because they preferred to follow up with their own primary care physician or an outside cardiologist.

Our algorithm provides a more simplified, reproducible, and practical approach to the care of patients presenting to the ED in rapid AF and AFL and has become the standard of care in our community hospital. We believe that this algorithm is the first of its kind to easily identify patients who are suitable for outpatient treatment.

Ann Arbor AFib Algorithm

References

  1. Lloyd-Jones DM, Wang TJ, Leip EP, et al. Lifetime risk for development of atrial fibrillation: the Framingham Heart Study. Circulation. Aug 31 2004;110(9):1042-1046.
  2. Elmouchi DA, VanOosterhout S, Muthusamy P, et al. Impact of an emergency department-initiated clinical protocol for the evaluation and treatment of atrial fibrillation. Crit Pathw Cardiol. Jun 2014;13(2):43-48.
  3. Coyne KS, Paramore C, Grandy S, Mercader M, Reynolds M, Zimetbaum P. Assessing the direct costs of treating nonvalvular atrial fibrillation in the United States. Value Health. Sep-Oct 2006;9(5):348-356.
  4. Raghavan AV, Decker WW, Meloy TD. Management of atrial fibrillation in the emergency department. Emerg Med Clin North Am. Nov 2005;23(4):1127-1139.
  5. Friberg J, Buch P, Scharling H, Gadsbphioll N, Jensen GB. Rising rates of hospital admissions for atrial fibrillation. Epidemiology. Nov 2003;14(6):666-672.
  6. Stiell IG, Clement CM, Brison RJ, et al. Variation in management of recent-onset atrial fibrillation and flutter among academic hospital emergency departments. Ann Emerg Med. Jan 2011;57(1):13-21.
  7. Barrett TW, Self WH, Jenkins CA, et al. Predictors of regional variations in hospitalizations following emergency department visits for atrial fibrillation. Am J Cardiol. Nov 1 2013;112(9):1410-1416.
  8. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation. Dec 2 2014;130(23):e199-267.




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