Effect of a Multidisciplinary Approach for the Management of Patients With Atrial Fibrillation in the Emergency Department on Hospital Admission Rate and Length of Stay

      Management of atrial fibrillation (AF) in the emergency department (ED) is variable because of the absence of universally adopted treatment guidelines. To address potentially preventable hospital admissions and prolonged length of stay, an AF treatment pathway was co-developed by physicians from the cardiac electrophysiology service and the department of emergency medicine at our institution. The impact of this AF pathway on patient outcomes was evaluated with a prospective, observational study conducted in a single tertiary care center from July 1, 2013, to June 30, 2014. The primary study outcome was the rate of hospital admission. The secondary outcomes were duration of ED visit and inpatient length of stay. The 94 patients treated according to the AF pathway during the study period were less likely to be admitted than the 265 patients who received routine care (16% vs 80%, p <0.001). For admitted patients, the mean length of stay was shorter for patients treated according to the AF pathway (32 vs 85 hours, p = 0.002). The time spent in the ED was longer for patients in the AF pathway (16 vs 85 hours, p <0.001). Utilization of a multidisciplinary pathway for management of AF in the ED led to a significant reduction in the rate of hospital admission. Patients who were admitted after receiving care according to the AF pathway had a shorter length of stay. In conclusion, utilization of a multidisciplinary AF pathway resulted in a 5-fold reduction in admission rate and >2-fold reduction length of stay for admitted patients.
      To read this article in full you will need to make a payment

      References

        • Coyne K.
        • 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. 2006; 9: 348-356
        • Kim M.
        • Johnston S.
        • Chu B.
        • Dalal M.
        • Scholman K.
        Estimation of total incremental health care costs in patients with atrial fibrillation in the United States.
        Circ Cardiovasc Qual Outcomes. 2011; 4: 313-320
        • Wattigney W.
        • Mensah G.
        • Croft J.
        Increasing trends in hospitalization for atrial fibrillation in the United States, 1985 through 1999: implications for primary prevention.
        Circulation. 2003; 108: 711-716
        • Friberg J.
        • Buch P.
        • Scharling H.
        • Gadsbphioll N.
        • Jensen G.
        Rising rates of hospital admissions for atrial fibrillation.
        Epidemiology. 2003; 14: 666-672
        • Naccarelli G.
        • Varker H.
        • Lin J.
        • Schulman K.
        Increasing prevalence of atrial fibrillation and flutter in the United States.
        Am J Cardiol. 2009; 104: 1534-1539
        • Roger V.
        • Go A.
        • Lloyd-Jones D.
        • Adams R.
        • Berry J.
        • Brown T.
        • Carnethon M.
        • Dai S.
        • de Simone G.
        • Ford E.
        • Fox C.
        • Fullerton H.
        • Gillespie C.
        • Greenlund K.
        • Hailpern S.
        • Heit J.
        • Ho P.
        • Howard V.
        • Kissela B.
        • Kittner S.
        • Lackland D.
        • Lichtman J.
        • Lisabeth L.
        • Makuc D.
        • Marcus G.
        • Marelli A.
        • Matchar D.
        • McDermott M.
        • Meigs J.
        • Moy C.
        • Mozaffarian D.
        • Mussolino M.
        • Nichol G.
        • Paynter N.
        • Rosamond W.
        • Sorlie P.
        • Stafford R.
        • Turan T.
        • Turner M.
        • Wong N.
        • Wylie-Rosett J.
        • American Heart Association Statistics Committee and Stroke Statistics Subcommittee
        Heart disease and stroke statistics—2011 update: a report from the American Heart Association.
        Circulation. 2011; 123: e18-e209
        • Benjamin E.
        • Wolf P.
        • D'Agostino R.
        • Silbershatz H.
        • Kannel W.
        • Levy D.
        Impact of atrial fibrillation on the risk of death: the Framingham Heart Study.
        Circulation. 1998; 98: 946-952
        • McDonald A.
        • Pelletier A.
        • Ellinor P.
        • Camargo C.J.
        Increasing US emergency department visit rates and subsequent hospital admissions for atrial fibrillation from 1993 to 2004.
        Ann Emerg Med. 2008; 51: 58-65
        • Sacchetti A.
        • Williams J.
        • Levi S.
        • Akula D.
        Impact of emergency department management of atrial fibrillation on hospital charges.
        West J Emerg Med. 2013; 14: 55-57
        • von Besser K.
        • Mills A.
        Is discharge to home after emergency department cardioversion safe for the treatment of recent-onset atrial fibrillation?.
        Ann Emerg Med. 2011; 58: 517-520
        • Decker W.
        • Smars P.
        • Vaidyanathan L.
        • Goyal D.
        • Boie E.
        • Stead L.
        • Packer D.
        • Meloy T.
        • Boggust A.
        • Haro L.
        • Laudon D.
        • Lobl J.
        • Sadosty A.
        • Schears R.
        • Schiebel N.
        • Hodge D.
        • Shen W.
        A prospective, randomized trial of an emergency department observation unit for acute onset atrial fibrillation.
        Ann Emerg Med. 2008; 52: 322-328
        • Stiell I.
        • Clement C.
        • Perry J.
        • Vaillancourt C.
        • Symington C.
        • Dickinson G.
        • Birnie D.
        • Green M.
        Association of the Ottawa aggressive protocol with rapid discharge of emergency department patients with recent-onset atrial fibrillation or flutter.
        CJEM. 2010; 12: 181-191
        • Fuster V.
        • Rydén L.
        • Cannom D.
        • Crijns H.
        • Curtis A.
        • Ellenbogen K.
        • Halperin J.
        • Kay G.
        • Le Huezey J.
        • Lowe J.
        • Olsson S.
        • Prystowsky E.
        • Tamargo J.
        • Wann L.
        2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in partnership with the European Society of Cardiology and in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.
        JACC. 2011; 57: e101-e198
        • January C.
        • Wann L.
        • Alpert J.
        • Calkins H.
        • Cigarroa J.
        • Cleveland J.J.
        • Conti J.
        • Ellinor P.
        • Ezekowitz M.
        • Field M.
        • Murray K.
        • Sacco R.
        • Stevenson W.
        • Tchou P.
        • Tracy C.
        • Yancy C.
        • Guidelines. American College of Cardiology/American Heart Association Task Force on Practice Guidelines
        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.
        JACC. 2014; 64: e1-e76
        • European Heart Rhythm Association, European Association for Cardio-Thoracic Surgery
        • Camm A.
        • Kirchhof P.
        • Lip G.
        • Schotten U.
        • Savelieva I.
        • Ernst S.
        • Van Gelder I.
        • Al-Attar N.
        • Hindricks G.
        • Prendergast B.
        • Heidbuchel H.
        • Alfieri O.
        • Angelini A.
        • Atar D.
        • Colonna P.
        • De Caterina R.
        • De Sutter J.
        • Goette A.
        • Gorenek B.
        • Heldal M.
        • Hohloser S.
        • Kolh P.
        • Le Heuzey J.
        • Ponikowski P.
        • Rutten F.
        Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC).
        Eur Heart J. 2010; 31: 2369-2429
        • Camm A.
        • Lip G.
        • De Caterina R.
        • Savelieva I.
        • Atar D.
        • Hohnloser S.
        • Hindricks G.
        • Kirchhof P.
        • ESC Committee for Practice Guidelines (CPG)
        2012 focused update of the ESC guidelines for the management of atrial fibrillation: an update of the 2010 ESC guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association.
        Eur Heart J. 2012; 33: 2719-2747
        • Verma A.
        • Cairns J.
        • Mitchell L.
        • Macle L.
        • Stiell I.
        • Gladstone D.
        • McMurtry M.
        • Connolly S.
        • Cox J.
        • Dorian P.
        • Ivers N.
        • Leblanc K.
        • Nattel S.
        • Healey J.
        • CCS Atrial Fibrillation Guidelines Committee
        2014 focused update of the Canadian Cardiovascular Society guidelines for the management of atrial fibrillation.
        Can J Cardiol. 2014; 30: 1114-1130
        • Stiell I.
        • Macle L.
        • CCS Atrial Fibrillation Committee
        Canadian Cardiovascular Society atrial fibrillation guidelines 2010: management of recent-onset atrial fibrillation and flutter in the emergency department.
        Can J Cardiol. 2011; 27: 38-46
        • Funk A.
        • Kocher K.
        • Rohde J.
        • West B.
        • Crawford T.
        • Froehlich J.
        • Saberi S.
        Variation in practice patterns among specialties in the acute management of atrial fibrillation.
        BMC Cardiovasc Disord. 2015; 15: 21
        • Stiell I.
        • Clement C.
        • Brison R.
        • Rowe B.
        • Borgundvaag B.
        • Langhan T.
        • Lang E.
        • Magee K.
        • Stenstrom R.
        • Perry J.
        • Birnie D.
        • Wells G.
        Variation in management of recent-onset atrial fibrillation and flutter among academic hospital emergency departments.
        Ann Emerg Med. 2011; 57: 13-21
        • Steinberg B.
        • Kim S.
        • Fonarow G.
        • Thomas L.
        • Ansell J.
        • Kowey P.
        • Mahaffey K.
        • Gersh B.
        • Hylek E.
        • Naccarelli G.
        • Go A.
        • Reiffel J.
        • Chang P.
        • Peterson E.
        • Piccini J.
        Drivers of hospitalization for patients with atrial fibrillation: results from the outcomes registry for better informed treatment of atrial fibrillation (ORBIT-AF).
        Am Heart J. 2014; 167: 735-742
        • R Core Team
        A Language and Environment for Statistical Computing.
        R Foundation for Statistical Computing, Vienna, Austria2014
        • Ho D.
        • Imai K.
        • King G.
        • Stuart E.
        MatchIt: Nonparametric preprocessing for parametric causal interference.
        J Stat Softw. 2011; 42: 1-28

      Linked Article