Decrease emergency department hospital admissions for acute atrial fibrillation

Principal Investigator: Dr Ian Stiell, professor, Department of Emergency Medicine, University of Ottawa; (OHRI) Ottawa Hospital Research Institute

Local Principal Investigator: Éric Mercier, emergency physician, trauma team leader and clinical researcher at the Centre de Recherche du CHU de Québec-Université Laval

Local Co-investigators: Émond, M ; Le Sage, N

Local research coordinator: Sandrine Hegg-Deloye

Granting agency: Cardiac Arrhythmia Network of Canada (CANet)

Decreasing Hospital Admissions from the Emergency Department for Acute Atrial Fibrillation

Acute atrial fibrillation and flutter (AAFF) episodes are characterized by very rapid heart rates which have been present for less than seven days and are highly symptomatic, disabling most patients. It is the most common type of palpitation treated in the Emergency Department (ED). Some Canadian hospitals are able to discharge 95% of AAFF patients seen and treated in the ED whereas others admit up to 40% of similar patients. In this era of hospital and ED crowding, we believe that discharge home directly from the ED is an effective and safe strategy that reduces the burden on the patient and the health care system. Our overall aim is to improve the care of patients presenting to the ED with AAFF, while decreasing unnecessary hospitalizations and reducing the overall length of stay in the ED, without increasing ED visits. We cannot improve the ED discharge rate and length of stay without a better understanding of what barriers there are at the local level. In our previous study (Project Ia), we conducted local in-depth interviews of emergency physicians, cardiologists and AAFF patients. In Project 1b, we created the CAEP ED AAFF Guidelines Checklist to assist physicians across Canada manage AAFF more efficiently and safely. The Guidelines are comprised of two algorithms and four sets of checklists for ED assessment and management. They have been endorsed by the Canadian Association of Emergency Physicians and have been published in the Canadian Journal of Emergency Medicine.

Building on Project 1, we are now planning Project 2 in which we will conduct a randomized trial at 10 large Canadian EDs and enroll 1,300 patients over a thirteen-month period. Our goal is to introduce the new CAEP ED Guidelines into these hospitals to improve the care provided to AAFF patients. We hope to improve the safety and efficiency of AAFF management, leading to a significant decrease in hospital admissions and ED length of stay. Central to our plans will be engagement of our two patient partners. Our behaviorally optimized intervention will be developed using state-of-the-art implementation science approaches informed by the results of Project 1a. We will also undertake widespread within-project and end-of-project knowledge translation and implementation (KTI) strategies to facilitate scale up and roll out of our program to ED departments in small, medium, and large hospitals across Canada (future Project 3). Ultimately, we expect to improve ED management practices and decrease AAFF admissions and length of stay, without increasing ED visits.

1.1 Project Hypothesis, Research Question(s) and Objectives

1.1.1 Project Hypothesis

Rapid ED discharge of acute atrial fibrillation (AAFF) patients is a safe strategy that will benefit both the patient and the healthcare system. Our premise is that if ED physicians can learn to successfully manage the rate and rhythm of AAFF patients, then most patients can be directly discharged home. We believe that our overall program will lead to a significant reduction in hospital admissions and length of stay in Canadian EDs for AAFF. At the same time, we are convinced that this strategy will not increase subsequent ED visits for these patients. In a multicentre prospective AAFF study, we showed that patients leaving the ED in sinus rhythm were less likely to have adverse events or return to the ED within 30 days.13 We expect that the current Project 2 will demonstrate the successful impact of the new guidelines at 10 sites. We will also develop the KTI tools to change physician behaviour in all EDs across Canada in Project 3. From Project 1a we are learning current Canadian practice patterns for the management of AAFF and are identifying barriers and enablers to rapid ED discharge. From Project 1b we have developed high-quality clinical practice guidelines, designed to be clinician friendly in the ED. This knowledge will allow us to improve the efficiency and effectiveness of ED care, and ultimately decrease unnecessary hospitalizations and ED length of stay across Canada.

1.1.2 Research Questions

1) Can we effectively design effective KTI strategies and tools for implementing the CAEP AAFF Guidelines?

2) Can we reduce hospital admissions and ED length of stay for AAFF patients seen in 10 Canadian EDs within a cluster-randomized implementation trial?

3) Can we effect compliance with the new CAEP AAFF Guidelines in terms of ED rhythm control, rate control, and proper prescription of oral anticoagulants?

4) Can we ensure that rapid ED discharge is not associated with an increase in subsequent ED visits?

1.1.3 Objectives

The overall goal of this program is to decrease hospital admissions and ED length of stay for AAFF. The specific objectives of this project are to:

1) Design effective KTI strategies and tools to encourage ED uptake of the CAEP AAFF Guidelines;

2) Conduct an implementation trial of the new adapted CAEP AAFF Guidelines to evaluate their effectiveness in actually reducing AAFF length of stay in the ED;

3) Evaluate the impact of the AAFF Guidelines on secondary outcomes of AAFF hospital admissions, rhythm control, rate control, and oral anticoagulant prescriptions;

4) Evaluate the impact on subsequent ED visits.