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Mattice AMS, Adler S, Eagles D, Yadav K, Hui S, Azward A, Pandey N, Stiell IG. Assessment of physician compliance to the CAEP 2021 Atrial Fibrillation Best Practices Checklist for rate and rhythm control in the emergency department. CAN J EMERG MED 2024; 26:333-338. [PMID: 38519830 DOI: 10.1007/s43678-024-00669-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 02/25/2024] [Indexed: 03/25/2024]
Abstract
OBJECTIVES Acute atrial fibrillation and flutter (AF/AFL) are common arrhythmias treated in the emergency department (ED). The 2021 CAEP Best Practices Checklist provides clear recommendations for management of patients with acute AF/AFL. This study aimed to evaluate physician compliance to Checklist recommendations for risk assessment and ED management of AF/AFL. METHODS This health records review assessed the management of adult patients presenting to two tertiary care EDs for management of acute AF/AFL from January to August, 2022. All ECGs demonstrating AF/AFL with a heart rate greater than 100 were compiled to capture primary and secondary causes. All visits were assessed for rate and rhythm control management, adverse events, return to ED, and safety criteria. Study physicians classified safety criteria from the Checklist into high and moderate concerns. The primary outcome was the proportion of cases with safety concerns and adverse events occurring during management in the ED. Data were analyzed using simple descriptive statistics. RESULTS We included 429 patients with a mean age of 67.7 years and 57.1% male. ED management included rate control (20.4%), electrical (40.1%), and pharmacological (20.1%) cardioversion. Adverse events occurred in 9.5% of cases: 12.5% in rate control, 13.4% in electrical cardioversion, and 6.9% in pharmacologic cardioversion. Overall, 7.9% of cases had management safety concerns. Moderate safety concerns occurred in 4.9% of cases including failure to attain recommended heart rate at time of discharge (3.9%). Severe concerns were identified in 3.0% of cases including failure to cardiovert unstable patients (1.2%). The 30-day return-to-ED rate was 16.5% secondary to AF/AFL. CONCLUSION ED management of AF/AFL was consistent with the CAEP Checklist and was safe overall. Opportunities for optimizing care include attaining recommended targets during rate control, avoidance of calcium channel and beta blockers in patients with systolic dysfunction, and earlier cardioversion for clinically unstable patients.
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Affiliation(s)
- Amanda M S Mattice
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
| | - Samara Adler
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Debra Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Krishan Yadav
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Sean Hui
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Althaf Azward
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Nikesh Pandey
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
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Addy K, Joyce LR, Al-Busaidi IS, Pickering JW, Troughton R, Than M. Implementation of an integrated emergency department acute atrial fibrillation pathway safely reduces cardioversions and hospitalisations: A comparative pre-post study. Emerg Med Australas 2023; 35:828-833. [PMID: 37169715 DOI: 10.1111/1742-6723.14240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/03/2023] [Accepted: 04/27/2023] [Indexed: 05/13/2023]
Abstract
OBJECTIVE Atrial fibrillation/flutter (AF/AFL) accounts for high rates of ED presentations and hospital admissions. There is increasing evidence to suggest that delaying cardioversion for acute uncomplicated AF is safe, and that many patients will spontaneously revert to sinus rhythm (SR). We conducted a before-and-after evaluation of AF/AFL management after a change in ED pathway using a conservative 'rate-and-wait' approach, incorporating next working day outpatient clinic follow-up and delayed cardioversion if required. METHODS We performed a before-and-after retrospective cohort study examining outcomes for patients who presented to the ED in Christchurch, New Zealand, with acute uncomplicated AF/AFL in the 1-year period before and after the implementation of a new conservative management pathway. RESULTS A total of 360 patients were included in the study (182 'Pre-pathway' vs 178 'Post-Pathway'). Compared to the pre-pathway cohort, those managed under the new pathway had an 81.2% reduction in ED cardioversions (n = 32 vs n = 6), and 50.7% reduction in all cardioversions (n = 65 vs n = 32). There was a 31.6% reduction in admissions from ED (n = 54 vs n = 79). ED length of stay (3.9 h vs 3.8 h, net difference -0.1 h, 95% confidence interval [CI] -0.6 to 0.3), 1-year ED AF representation (32.4% vs 26.4%, net difference -6.0% [95% CI -16.0% to 3.9%]), 1-year ED ischaemic stroke presentation (2.2% in both groups) and 7-day all-cause mortality rates (hazard ratio 1.05 [95% CI 0.6 to 1.9]) were all similar. CONCLUSIONS Using a conservative 'rate-and-wait' strategy with early follow-up for patients presenting to ED with AF/AFL can safely reduce unnecessary cardioversions and avoidable hospitalisations.
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Affiliation(s)
- Kaleb Addy
- Department of General Medicine, Auckland City Hospital, Auckland, New Zealand
- Department of Surgery and Critical Care, University of Otago, Christchurch, New Zealand
| | - Laura R Joyce
- Department of Surgery and Critical Care, University of Otago, Christchurch, New Zealand
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Ibrahim S Al-Busaidi
- Department of Primary Care and Clinical Simulation, University of Otago, Christchurch, New Zealand
- Department of Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - John W Pickering
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Richard Troughton
- Department of Medicine, University of Otago, Christchurch, New Zealand
- Cardiology Department, Christchurch Hospital, Christchurch, New Zealand
| | - Martin Than
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
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Manzo-Silberman S, Chouihed T, Fraticelli L, Charpentier S, Claustre C, Bonnefoy-Cudraz E, Elbaz M, Peiretti A, Taboulet P, Waintraub X, Roubille F, El Khoury C. Assessment of atrial fibrillation in European emergency departments: insights from a prospective observational multicenter study. Minerva Cardiol Angiol 2023; 71:444-455. [PMID: 36422468 DOI: 10.23736/s2724-5683.22.06179-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
BACKGROUND The diagnosis and management of atrial fibrillation (AF) in emergency departments (EDs) have not been well described in France, with limited EU research. This study aimed to describe the diagnosis, management, and prognosis of AF patients in French EDs. METHODS A prospective, observational 2-month study in adults diagnosed with AF was conducted at 32 French EDs. Data regarding patient characteristics, diagnosis, and treatment at EDs were collected, with 12-month follow-up. RESULTS The study included a total of 1369 patients diagnosed with AF at an ED: 279 patients (20.4%) with idiopathic AF (no identified cause of the AF) and 1090 (79.6%) with secondary AF (with a principal diagnosis identified as the cause of AF). Patients were aged 84 years (median) and 51.3% were female. Significantly more idiopathic AF patients than secondary AF patients underwent CHA<inf>2</inf>DS<inf>2</inf>-VASc assessment (67.8% vs. 52.1%,) or echocardiography (21.2% vs. 8.3%), or received an oral anticoagulant and/or antiarrhythmic (62.0% vs. 12.9%). Idiopathic AF patients also had significantly higher rates of discharge to home (36.4% vs. 20.4%) and 3-month cardiologist follow-up (67.0% vs. 41.1%). At 12 months, 96% of patients with follow-up achieved sinus rhythm. The estimated Kaplan-Meier 12-month mortality rate was significantly lower with idiopathic AF than secondary AF (11.9% vs. 34.5%). CONCLUSIONS Patients diagnosed with idiopathic or secondary AF at the ED presented heterogeneous characteristics and prognoses, with those with secondary AF having worse outcomes. Further studies are warranted to optimize patients' initial evaluation in EDs and provide appropriate follow-up.
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Affiliation(s)
- Stéphane Manzo-Silberman
- Institute of Cardiology, Pitié-Salpêtrière Hospital, AP-HP, Sorbonne University, ACTION Study Group, Paris, France -
| | - Tahar Chouihed
- Emergency Department, University Hospital of Nancy, University of Lorraine, Vandoeuvre-les-Nancy, France
- Cliniques-Inserm 1433 Investigation Center, Inserm UMR_S 1116, F-CRIN INI-CRCT, Vandoeuvre-les-Nancy, France
| | - Laurie Fraticelli
- Auvergne Rhône-Alpes Agency for Health, RESCUe Network, Lyon, France
- EA4129, Systemic Health Pathway Laboratory, Lyon, France
| | | | - Clément Claustre
- Auvergne Rhône-Alpes Agency for Health, RESCUe Network, Lyon, France
| | | | - Meyer Elbaz
- Department of Cardiology, Rangueil University Hospital, Toulouse, France
| | | | - Pierre Taboulet
- Emergency Department, Saint-Louis Hospital, AP-HP, Paris, France
| | - Xavier Waintraub
- Institute of Cardiology, Pitié-Salpêtrière Hospital, AP-HP, Sorbonne University, ACTION Study Group, Paris, France
| | - François Roubille
- Department of Cardiology, Montpellier University Hospital, Montpellier, France
| | - Carlos El Khoury
- Clinical Research Unit, Emergency Department, Médipôle Hôpital Mutualiste, Lyon, France
- HESPER EA7425, University Lyon1, Lyon, France
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Bager JE, Martín A, Carbajosa Dalmau J, Simon A, Merino JL, Ritz B, Hartikainen JE. Vernakalant for Cardioversion of Recent-Onset Atrial Fibrillation in the Emergency Department: The SPECTRUM Study. Cardiology 2022; 147:566-577. [PMID: 36282074 PMCID: PMC9808723 DOI: 10.1159/000526831] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 08/20/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Intravenous vernakalant is a therapeutic option for symptomatic, recent-onset atrial fibrillation (AF). This secondary analysis from the large SPECTRUM study assessed the safety and effectiveness of vernakalant when used in the emergency department setting (ED group) or in an inpatient hospital setting (non-ED group). METHODS This post hoc analysis of the international, observational, post-authorization SPECTRUM study included 1,289 and 720 recent-onset AF episodes in adults in the ED and non-ED groups, respectively. Safety endpoints included the evaluation of pre-defined health outcomes of interest (HOIs) and other serious adverse events (SAEs) during vernakalant treatment and during the first 24 h after the last infusion. Effectiveness endpoints comprised the rate of successful vernakalant cardioversion, the time from the start of the vernakalant infusion to cardioversion, and the length of hospital stay. Data were analysed using descriptive statistics. RESULTS The safety profile of vernakalant was similar in the ED and non-ED groups. In the ED group, 12 pre-defined HOIs were reported in 11 patients (0.9%); all but one occurred within 2 h after start of the first infusion. These events comprised nine significant bradycardia cases, of which one was associated with transient hypotension and three with sinus arrest, and 2 cases of atrial flutter with 1:1 conduction. Five other SAEs were reported. All patients with vernakalant-related events recovered without sequelae. No Torsade de Pointes, ventricular fibrillation, or deaths occurred. Successful cardioversion was reported in 67.8% (95% confidence interval: 65.2-70.4) and 66.4% (62.5-70.1) of episodes, with a median time to conversion of 11.0 and 10.0 min in the ED and non-ED groups, respectively. Patients had a median length of hospital stay of 7.4 h and 17.1 h in the ED and non-ED groups, respectively. CONCLUSION Intravenous vernakalant was well tolerated with similar cardioversion rates in patients treated in the ED or non-ED setting and does not require admission to a coronary care unit or intensive care unit. First-line treatment with vernakalant could allow an early discharge in patients with recent-onset AF treated in the ED.
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Affiliation(s)
- Johan-Emil Bager
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden,Department of Emergency Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Alfonso Martín
- Emergency Department, University Hospital of Móstoles, Madrid, Spain,*Alfonso Martín,
| | | | - Alexander Simon
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - José L. Merino
- Department of Cardiology, La Paz University Hospital, IDIPAZ, Universidad Autónoma de Madrid, Madrid, Spain
| | - Beate Ritz
- Medical Information Department, ADVANZ PHARMA Switzerland Sàrl, Geneva, Switzerland
| | - Juha E.K. Hartikainen
- Heart Center Department, Kuopio University Hospital, Kuopio, Finland,University of Eastern Finland, Kuopio, Finland
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Masica A, Brown R, Farzad A, Garrett JS, Wheelan K, Nguyen HL, Ogola GO, Kudyakov R, McDonald B, Boyd B, Patel A, Delaughter C. Effectiveness of an algorithm-based care pathway for patients with non-valvular atrial fibrillation presenting to the emergency department. J Am Coll Emerg Physicians Open 2022; 3:e12608. [PMID: 35224547 PMCID: PMC8857555 DOI: 10.1002/emp2.12608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 09/24/2021] [Accepted: 10/06/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Atrial fibrillation (AF) carries substantial morbidity and mortality. Evidence-based guidelines have been synthesized into emergency department (ED) AF care pathways, but the effectiveness and scalability of such approaches are not well established. We thus evaluated the impacts of an algorithmic care pathway for ED management of non-valvular AF (EDAFMP) on hospital use and care process measures. METHODS We deployed a voluntary-use EDAFMP in 4 EDs (1 tertiary hospital, 1 cardiac hospital, 2 community hospitals) of an integrated delivery organization using a multifaceted implementation approach. We compared outcomes between patients with AF treated using the EDAFMP and historical and contemporaneous "usual care" controls, using a propensity-score adjusted generalized estimating equation. Patients with an index ED encounter for a primary visit reason of non-valvular AF (and no excluding concurrent diagnoses) were eligible for inclusion. RESULTS Preimplementation (January 1, 2016-December 31, 2016), 628 AF patients were eligible; postimplementation (September 1, 2017-June 30, 2019), 1296, including 271 (20.9%) treated with the EDAFMP, were eligible. EDAFMP patients were less likely to be admitted than both historical (adjusted odds ratio [aOR], 95% confidence interval [CI]: 0.45, 0.29-0.71) and contemporaneous controls (aOR, 95%CI: 0.63, 0.46-0.86). ED visits and hospital readmissions over 90 days subsequent to index ED encounters were similar between postimplementation EDAFMP and usual care groups. EDAFMP patients were more likely to be prescribed anticoagulation (38% v. 5%, P < 0.001) and be referred to a cardiologist (93% vs 29%, P < 0.001) versus the comparator group. CONCLUSION EDAFMP use is associated with decreased hospital admission during an index ED encounter for non-valvular AF, and improved delivery of AF care processes.
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Affiliation(s)
- Andrew Masica
- Center for Clinical EffectivenessBaylor Scott & White HealthDallasTexasUSA
- Texas Health ResourcesArlingtonTexasUSA
| | - Rachel Brown
- Center for Clinical EffectivenessBaylor Scott & White HealthDallasTexasUSA
- UChicago MedicineChicagoIllinoisUSA
| | - Ali Farzad
- Texas A&M College of MedicineDallasTexasUSA
- Department of Emergency MedicineBaylor University Medical CenterDallasTexasUSA
| | - John S. Garrett
- Texas A&M College of MedicineDallasTexasUSA
- Integrative Emergency ServicesDallasTexasUSA
| | - Kevin Wheelan
- Baylor Heart and Vascular Hospital DallasDallasTexasUSA
| | - Hoa L. Nguyen
- Center for Clinical EffectivenessBaylor Scott & White HealthDallasTexasUSA
- Department of Population and Quantitative Health SciencesUniversity of Massachusetts School of MedicineWorcesterMassachusettsUSA
| | | | - Rustam Kudyakov
- Center for Clinical EffectivenessBaylor Scott & White HealthDallasTexasUSA
| | - Brandy McDonald
- Center for Clinical EffectivenessBaylor Scott & White HealthDallasTexasUSA
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Sadaf MI, O'Bryan J, Biese K, Chen S, Deyo Z, Mendys P, Sears SF, Tuttle H, Walker TJ, Gehi AK. Characteristics of patients presenting to emergency department for primary atrial fibrillation or flutter at an academic medical center. Indian Heart J 2021; 73:588-593. [PMID: 34627574 PMCID: PMC8514404 DOI: 10.1016/j.ihj.2021.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 07/04/2021] [Accepted: 08/16/2021] [Indexed: 11/02/2022] Open
Abstract
OBJECTIVE In the United States, atrial fibrillation (AF) accounts for over 400,000 hospitalizations annually. Emergency Department (ED) physicians have few resources available to guide AF/AFL (atrial flutter) patient triage, and the majority of these patients are subsequently admitted. Our aim is to describe the characteristics and disposition of AF/AFL patients presenting to the University of North Carolina (UNC) ED with the goal of developing a protocol to prevent unnecessary hospitalizations. METHODS We performed a retrospective electronic medical chart review of AF/AFL patients presenting to the UNC ED over a 15-month period from January 2015 to March 2016. Demographic and ED visit variables were collected. Additionally, patients were designated as either having primary or secondary AF/AFL where primary AF/AFL patients were those in whom AF/AFL was the primary reason for ED presentation. These primary AF/AFL patients were categorized by AF symptom severity score according to the Canadian Cardiovascular Society Severity of Atrial Fibrillation (CCS-SAF) Scale. RESULTS A total of 935 patients presented to the ED during the study period with 202 (21.5%) having primary AF/AFL. Of the primary AF/AFL patients, 189 (93.6%) had mild-moderate symptom severity (CCS-SAF ≤ 3). The majority of primary AF/AFL patients were hemodynamically stable, with a mean (SD) SBP of 123.8 (21.3), DBP of 76.6 (14.1), and ventricular rate of 93 (21.9). Patients with secondary AF/AFL were older 76 (13.1), p < 0.001 with a longer mean length of stay 6.1 (7.7), p = 0.31. Despite their mild-moderate symptom severity and hemodynamic stability, nearly 2/3 of primary AF/AFL patients were admitted. CONCLUSION Developing a protocol to triage and discharge hemodynamically stable AF/AFL patients without severe AF/AFL symptoms to a dedicated AF/AFL clinic may help to conserve healthcare resources and potentially deliver more effective care.
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Affiliation(s)
- Murrium I Sadaf
- Department of Internal Medicine, Yale-New Haven Medical Center, New Haven, CT, USA
| | - James O'Bryan
- Department of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Kevin Biese
- Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Sarah Chen
- Division of Cardiology, Department of Internal Medicine, Chapel Hill, NC, USA
| | - Zachariah Deyo
- Department of Pharmacy, UNC Medical Center, Chapel Hill, NC, USA
| | - Phil Mendys
- Department of Pharmacy, UNC Medical Center, Chapel Hill, NC, USA; North American Medical Affairs, Pfizer, NY UNC, USA
| | - Samuel F Sears
- Departments of Psychology, Cardiovascular Sciences, and Public Health, East Carolina University, Greenville, NC, USA
| | - Heather Tuttle
- Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - T Jennifer Walker
- Division of Cardiology, Department of Internal Medicine, Chapel Hill, NC, USA
| | - Anil K Gehi
- Division of Cardiology, Department of Internal Medicine, Chapel Hill, NC, USA.
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Rationale, considerations, and goals for atrial fibrillation centers of excellence: A Heart Rhythm Society perspective. Heart Rhythm 2020; 17:1804-1832. [DOI: 10.1016/j.hrthm.2020.04.033] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 04/27/2020] [Indexed: 12/19/2022]
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Abadie BQ, Hansen B, Walker J, Deyo Z, Biese K, Armbruster T, Tuttle H, Sadaf MI, Sears SF, Pasi R, Gehi AK. Likelihood of Spontaneous Cardioversion of Atrial Fibrillation Using a Conservative Management Strategy Among Patients Presenting to the Emergency Department. Am J Cardiol 2019; 124:1534-1539. [PMID: 31522772 DOI: 10.1016/j.amjcard.2019.08.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 08/06/2019] [Accepted: 08/08/2019] [Indexed: 01/08/2023]
Abstract
Numerous emergency department (ED) atrial fibrillation (AF) protocols have been developed to reduce hospitalizations, focusing on the use of cardioversion in the ED. An alternative strategy of rate control with early specialty follow-up may be more widely applicable. The likelihood of spontaneous cardioversion with such a protocol is unknown. Between 2015 and 2018, 157 patients who presented to the ED with a primary diagnosis of AF and were hemodynamically stable and with low to moderate symptom severity were discharged with early follow-up at an AF specialty clinic. Rhythm at short-term (within 72 hours), within 30-day follow-up, and need for electrical cardioversion was tabulated. Various demographic and co-morbidity variables were assessed to determine their association with likelihood of spontaneous cardioversion. At an average of 2.3 days, 63% and within 30 days, 83% had spontaneous cardioversion. By 90 days, only 6.3% required electrical cardioversion. Diabetes (38% vs 69%, p <0.01), coronary artery disease (39% vs 66%, p = 0.02), reduced ejection fraction (40% vs 72%, p <0.01), dilated right atrium (43% vs 73%, p <0.01) and moderate-to-severely dilated left atrium (38% vs 78%, p <0.01) predicted those who were less likely to convert to sinus rhythm. Most patients who present to the ED with AF will spontaneously convert to sinus rhythm by short-term (2 to 3 days) follow-up with a rate control strategy. In conclusion, aggressive use of electrical cardioversion in the ED may be unnecessary in hemodynamically stable patients without severe symptoms.
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Interventions to Improve Emergency Department-Related Transitions in Care for Adult Patients With Atrial Fibrillation and Flutter. J Emerg Med 2019; 57:501-516. [PMID: 31543438 DOI: 10.1016/j.jemermed.2019.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/14/2019] [Accepted: 06/04/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Patients presenting to emergency departments (EDs) with acute atrial fibrillation or flutter undergo numerous transitions in care (TiC), including changes in their provider, level of care, and location. During transitions, gaps in communications and care may lead to poor outcomes. OBJECTIVE We sought to examine the effectiveness of ED-based interventions to improve length of stay, return to normal sinus rhythm, and hospitalization, among other critical patient TiC outcomes. METHODS Comprehensive searches of electronic databases and the gray literature were conducted. Two independent reviewers completed study selection, quality, and data extraction. Relative risks (RRs) with 95% confidence intervals (CIs) were calculated using a random-effects model, where appropriate. RESULTS From 823 citations, 11 studies were included. Interventions consisted of within-ED clinical pathways (n = 6) and specialized observation units (n = 2) and post-ED structured patient education and referrals (n = 3). Three of five studies assessing hospital length of stay reported a significant decrease associated with TiC interventions. Patients undergoing within-ED interventions were also more likely to receive electrical cardioversion. Two of 3 clinical pathways reporting hospitalization proportions showed significant decreases associated with TiC interventions (RR = 0.63 [95% CI 0.42-0.92] and RR = 0.20 [95% CI 0.12-0.32]), as did 1 observation unit (RR = 0.54 [95% CI 0.36-0.80]). No significant differences in mortality, complications, or relapse were found between groupings among the studies. CONCLUSIONS There is low to moderate quality evidence suggesting that within-ED TiC interventions may reduce hospital length of stay and decrease hospitalizations. Additional high-quality comparative effectiveness studies, however, are warranted.
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