Optimizing the Management of Emergency Department Patients with Atrial Fibrillation
Heather Tuttle, BS, BSN, RN, CEN; Zack Deyo, PharmD, BCPS, CPP; Terra Beek, BA, BSN, RN, CEN; Leah Hatfield, PharmD, BCPS; Philip Mendys, PharmD, FAHA, CPP; Kevin Biese, MD, MAT; Anil Gehi, MD
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Session F presented Friday, September 15, 2017
Purpose: Atrial Fibrillation is the most common cardiac dysrhythmia in adults, with an annual cost of care estimated at $6.65 billion (3/4 of cost due to hospitalization), and greater than 70% of patients admitted with AF enter the system through the emergency department.
Design: By providing a multidisciplinary structured model of care, connecting Emergency Medicine and Cardiology practices, we hypothesized that a novel pathway from the ED to an Atrial Fibrillations Clinic to coordinate care, modify risk factors, and promote patient self-care could: reduce unnecessary AF hospital admissions, and improve quality of AF care. An Atrial Fibrillation Nurse Coordinator (AFNC) was incorporated, to provide education, assist with clinical implementation, and to perform quality analysis of patient care.
Setting: University of North Carolina (UNC) Medical Center - 804-bed academic medical center in Chapel Hill, 90-bed ED, Over 72,000 annual visits, 1 Clinical Pharmacist; Hillsborough Campus - 72-bed community hospital extension in Hillsborough,
10-bed emergency department; Cardiology Clinic at Meadowmont - Over 16,000 annual visits, 20 Attending Physicians, 3 Clinical Pharmacists.
Participants/Subjects: A 3 month review of internal data showed 214 patients presented to our ED with an ECG diagnosis of AF. Of the 49 patients with a primary ED diagnosis of AF, 41 were admitted (83.7%), with average LOS of 3.0 days.
Methods: Working group sessions were used to develop a triage protocol to risk stratify patients presenting to the ED with AF. A scheduling system was developed and, all patients were to be provided a date and time for follow up in clinic, within 72 hours. An ED evaluation template was created to guide providers through their ED assessment. Training sessions for all ED staff were led by AFNC. Patient education materials, with a focus on risk reduction and self-care during AF episodes, were created within the EHR. The AFNC tracked all referrals for compliance. All ED providers received closed-loop communication from AFNC and clinic providers, regarding patient's clinic visit. AFNC attempted contact for all "No Show" patients.
Results/Outcomes: In July of 2015, we deployed the protocol to triage and discharge patients who present to the ED with AF: 98 patients presented to our ED with a primary diagnosis of AF; 60 of these patients were admitted to the hospital with 56 discharged from the ED; The admission rate was reduced from 80.7% pre-implementation to 51.7% post-implementation (p < 0.001); The average per patient hospital LOS was 2.5 days; Re-presentation rate to the ED with a primary diagnosis of AF at 90 days was not significantly increased; 37 followed up in the AF Transitions Clinic (primary diagnosis of AF);
57 total patients seen in AF Transitions Clinic (including ED patients with secondary diagnosis of AF); Mean time to clinic visit of 3 days; 67.8% were seen in 24 to 48 hours; 1 patient did not attend clinic visit.
Implications: We successfully implemented a novel care pathway to triage and discharge AF patients from the emergency department, with early, specialty care follow up that dramatically changed practice in our health system, and can be implemented with other chronic diseases.
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