Impact of a Multidisciplinary Treatment Pathway for Atrial Fibrillation in the Emergency Department on Hospital Admissions and Length of Stay: Results of a Multi-Center Study

Leon M Ptaszek, Christopher W Baugh, Steven A Lubitz, Jeremy N Ruskin, Grace Ha, Margaux Forsch, Samer A DeOliveira, Samia Baig, E Kevin Heist, Jason H Wasfy, David F Brown, Paul D Biddinger, Ali S Raja, Benjamin Scirica, Benjamin A White, Moussa Mansour, Leon M Ptaszek, Christopher W Baugh, Steven A Lubitz, Jeremy N Ruskin, Grace Ha, Margaux Forsch, Samer A DeOliveira, Samia Baig, E Kevin Heist, Jason H Wasfy, David F Brown, Paul D Biddinger, Ali S Raja, Benjamin Scirica, Benjamin A White, Moussa Mansour

Abstract

Background Variability in the management of atrial fibrillation (AF) in the emergency department (ED) leads to avoidable hospital admissions and prolonged length of stay (LOS). In a retrospective single-center study, a multidisciplinary AF treatment pathway was associated with a reduced hospital admission rate and reduced LOS. To assess the applicability of the AF pathway across institutions, we conducted a 2-center study. Methods and Results We performed a prospective, 2-stage study at 2 tertiary care hospitals. During the first stage, AF patients in the ED received routine care. During the second stage, AF patients received care according to the AF pathway. The primary study outcome was hospital admission rate. Secondary outcomes included ED LOS and inpatient LOS. We enrolled 104 consecutive patients in each stage. Patients treated using the AF pathway were admitted to the hospital less frequently than patients who received routine care (15% versus 55%; P<0.001). For admitted patients, average hospital LOS was shorter in the AF pathway cohort than in the routine care cohort (64 versus 105 hours, respectively; P=0.01). There was no significant difference in the average ED LOS between AF pathway and routine care cohorts (14 versus 12 hours, respectively; P=0.32). Conclusions In this prospective 2-stage, 2-center study, utilization of a multidisciplinary AF treatment pathway resulted in a 3.7-fold reduction in admission rate and a 1.6-fold reduction in average hospital LOS for admitted patients. Utilization of the AF pathway was not associated with a significant change in ED LOS.

Keywords: atrial fibrillation; cardioversion; emergency department; oral anticoagulant.

Figures

Figure 1
Figure 1
Diagram of the multidisciplinary AF treatment pathway. Prompt cardiac electrophysiology (EP) consultation was obtained for all enrolled patients. This was followed by discussion between the EP and emergency medicine (EM) clinicians to determine the appropriate treatment strategy (rhythm vs rate control). If a rhythm control strategy was chosen, the EP team assisted in expediting cardioversion. The EP team also assisted in the choice of the most appropriate anticoagulant irrespective of the choice of rhythm or rate control strategy. The EP and EM clinicians then assessed the patient's response to therapy and determined the patient's candidacy for discharge from the emergency department (ED). AF indicates atrial fibrillation; NOAC, novel oral anticoagulant; TEE, transesophageal echocardiography.
Figure 2
Figure 2
Design of the multicenter, prospective, 2‐stage study of the AF treatment pathway. All patients presenting with AF to the ED at both participating institutions were screened for inclusion in the study. Patients were enrolled if they presented with AF as a primary problem, met the inclusion criteria, and did not meet the exclusion criteria. In stage 1 of the study, enrolled patients received routine care. In stage 2 of the study, enrolled patients were treated according to the AF pathway, as described in Figure 1. At the conclusion of the study, impact of the AF pathway on the primary and secondary study outcomes was determined. AF indicates atrial fibrillation; ED, emergency department; LOS, length of stay; OAC, oral anticoagulant.
Figure 3
Figure 3
Impact of AF pathway utilization on inpatient admission rate and length of stay (LOS). A, Bar graph that describes hospital admission rates in the routine care and AF treatment pathway cohorts. Significantly fewer patients treated according to the AF pathway were admitted to an inpatient unit (P<0.001). B, Box plots that describe total hospital LOS (ED LOS plus inpatient LOS) for patients who were admitted from the ED to an inpatient unit. Box limits represent the first and third quartiles. The line within the box represents the median value. Whiskers represent the most extreme data points that are not more than 1.5 times the length of the box away from the box border. Circles represent outlier data points. Mean hospital LOS was significantly shorter for patients treated according to the AF pathway (P=0.01). C, Box plots that describe ED LOS for all patients, irrespective of admission status. Format of the box plots is the same as displayed in (B). There was not a statistically significant difference in time spent in the ED for the 2 study cohorts (P=0.32). AF indicates atrial fibrillation; ED, emergency department.
Figure 4
Figure 4
Kaplan–Meier estimate of the probability of discharge for patients in the AF pathway and routine care cohorts. Probability of discharge as a function of time after arrival in the ED was calculated for all patients in both study cohorts. Kaplan–Meier curves for the AF pathway and routine care cohorts reveal a significantly higher probability of discharge for patients treated according to the AF pathway (P<0.001). AF indicates atrial fibrillation; ED, emergency department.

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