The AFFORD clinical decision aid to identify emergency department patients with atrial fibrillation at low risk for 30-day adverse events

Emergency medicine updates: Atrial fibrillation with rapid ventricular response

INTRODUCTION

Atrial fibrillation (AF) may lead to stroke, heart failure, and death. When AF occurs in the context of a rapid ventricular rate/response (RVR), this can lead to complications, including hypoperfusion and cardiac ischemia. Emergency physicians play a key role in the diagnosis and management of this dysrhythmia.

OBJECTIVE

This paper evaluates key evidence-based updates concerning AF with RVR for the emergency clinician.

DISCUSSION

Differentiating primary and secondary AF with RVR and evaluating hemodynamic stability are vital components of ED assessment and management. Troponin can assist in determining the risk of adverse outcomes, but universal troponin testing is not required in patients at low risk of acute coronary syndrome or coronary artery disease - especially patients with recurrent episodes of paroxysmal AF that are similar to their prior events. Emergent cardioversion is indicated in hemodynamically unstable patients. Rate or rhythm control should be pursued in hemodynamically stable patients. Elective cardioversion is a safe option for select patients and may reduce AF symptoms and risk of AF recurrence. Rate control using beta blockers or calcium channel blockers should be pursued in those with AF with RVR who do not undergo cardioversion. Anticoagulation is an important component of management, and several tools (e.g., CHA2DS2-VASc) are available to assist with this decision. Direct oral anticoagulants are the first-line medication class for anticoagulation. Disposition can be challenging, and several risk assessment tools (e.g., RED-AF, AFFORD, and the AFTER (complex, modified, and pragmatic) scores) are available to assist with disposition decisions.

CONCLUSION

An understanding of the recent updates in the literature concerning AF with RVR can assist emergency clinicians in the care of these patients.

Implementation of an Atrial Fibrillation Decision Aid Care Pathway in the Emergency Department Reduces Atrial Fibrillation Hospitalizations

BACKGROUND

A straightforward decision aid to guide disposition of atrial fibrillation (AF) patients in the emergency department (ED) was developed for use by ED providers. The implementation of this decision aid in the ED has not been studied.

METHODS

A pragmatic stepped-wedge cluster approach for analysis of retrospectively collected electronic health record data was used in which 5 hospitals were selected to commence the intervention at periodic intervals following an initial 1-year baseline assessment with 5 additional hospitals included in the comparison group (all in North Carolina). The primary end point of analysis was hospitalization rate. Hierarchical multivariable logistic regression analyses for admission as a function of the intervention while controlling for prespecified patient and hospital predictors were performed with clustering done at the hospital level.

RESULTS

Between October 2017 and May 2020, a total of 11 458 patients (mean age, 71.4; 50.5% female) presented to 1 of the 10 hospitals with a primary diagnosis of AF. Absolute admission rate was reduced from 60.5% to 48.3% following the intervention (odds ratio, 0.83 [95% CI, 0.71-0.97]; P=0.016). After adjusting for covariates, the intervention was associated with a small increased rate of return to the ED for AF within 30 days of the initial presentation (1.6% to 2.7%; hazard ratio, 1.70 [95% CI, 1.26-2.31]; P<0.001).

CONCLUSIONS

We demonstrate that implementation of a novel decision aid to guide disposition of patients primary diagnosis of AF presenting to the ED was associated with a reduced admission rate independent of patient and hospital factors. Use of the protocol was associated with a small but significant increase in rate of repeat presentations for AF at 30-day follow-up. Use of a decision aid such as the one described here represents an important tool to reduce unnecessary AF hospitalizations.

Evidence That Nurses Need to Participate in Diagnosis: Lessons From Malpractice Claims

OBJECTIVES

There is a pressing need for nurses to contribute as equals to the diagnostic process. The purpose of this article is twofold: (a) to describe the contributing factors in diagnosis-related and failure-to-monitor malpractice claims in which nurses are named the primary responsible party and (b) to describe actions healthcare leaders can take to enhance the role of nurses in diagnosis.

METHODS

We conducted a review of the Controlled Risk Insurance Company Strategies' repository of malpractice claims, which contain approximately 30% of United States claims. We analyzed the malpractice claims related to diagnosis (n = 139) and physiologic monitoring (n = 647) naming nurses as the primary responsible party from 2007 to 2016. We used logistic regression to determine the association of contributing factors to likelihood of death, indemnity, and expenses incurred.

RESULTS

Diagnosis-related cases listing communication among providers as a contributing factor were associated with a significantly higher likelihood of death (odds ratio [OR] = 3.01, 95% confidence interval [CI] = 1.50-6.03). Physiologic monitoring cases listing communication among providers as a contributing factor were associated with significantly higher likelihood of death (OR = 2.21, 95% CI = 1.49-3.27), higher indemnity incurred (U.S. $86,781, 95% CI = $18,058-$175,505), and higher expenses incurred (U.S. $20,575, 95% CI = $3685-$37,465).

CONCLUSIONS

Nurses are held legally accountable for their role in diagnosis. Raising system-wide awareness of the critical role and responsibility of nurses in the diagnostic process and enhancing nurses' knowledge and skill to fulfill those responsibilities are essential to improving diagnosis.

LVS-HARMED Risk Score for Incident Heart Failure in Patients With Atrial Fibrillation Who Present to the Emergency Department: Data from a World-Wide Registry

Background Heart failure (HF) is a common complication to atrial fibrillation (AF), leading to rehospitalization and death. Early identification of patients with AF at risk for HF might improve outcomes. We aimed to derive a score to predict 1-year risk of new-onset HF after an emergency department (ED) visit with AF. Methods and Results The RE-LY AF (Randomized Evaluation of Long-Term Anticoagulant Therapy) registry enrolled patients with AF presenting to an ED in 47 countries, and followed them for a year. The end point was HF hospitalization and/or HF death. Among 15 400 ED patients, 9765 had no prior HF (mean age, 64.9±14.9 years). Within 1 year, new-onset HF developed in 6.8% of patients, of whom 21% died of HF. Independent predictors of HF included left ventricular hypertrophy (odds ratio [OR], 1.47; 95% CI, 1.19-1.82), valvular heart disease (OR, 1.55; 95% CI, 1.18-2.04), smoking (OR, 1.42; 95% CI, 1.12-1.78), height (OR, 0.93; 95% CI, 0.90-0.95 per 3 cm), age (OR, 1.11; 95% CI, 1.07-1.15 per 5 years), rheumatic heart disease (OR, 1.77, 95% CI, 1.24-2.51), prior myocardial infarction (OR, 1.85; 95% CI, 1.45-2.36), remaining in AF at ED discharge (OR, 1.86; 95% CI, 1.46-2.36), and diabetes (OR, 1.33; 95% CI, 1.09-1.64). A continuous risk prediction score (LVS-HARMED [left ventricular, valvular heart disease, smoking or other tobacco use, height, age, rheumatic heart disease, myocardial infarction, emergency department discharge rhythm, and diabetes]) had good discrimination (C statistic, 0.735; 95% CI, 0.716-0.755). Validation was conducted internally using bootstrapping (optimism-corrected C statistic, 0.705) and externally (C statistic, 0.699). The 1-year incidence of HF hospitalization and/or HF death across quartile groups of the score was 1.1%, 4.5%, 6.9%, and 14.4%, respectively. LVS-HARMED also predicted incident stroke (C statistic, 0.753; 95% CI, 0.728-0.778). Conclusions The LVS-HARMED score predicts new-onset HF after an ED visit for AF. Preventative strategies should be considered in patients with high LVS-HARMED HF risk.

Predictors of Acute Atrial Fibrillation and Flutter Hospitalization across 7 U.S. Emergency Departments: A Prospective Study

INTRODUCTION

International rates of hospitalization for atrial fibrillation and flutter (AFF) from the emergency department (ED) vary widely without clear evidence to guide the identification of high-risk patients requiring inpatient management. We sought to determine (1) variation in hospital admission and (2) modifiable factors associated with hospitalization of AFF patients within a U.S. integrated health system.

METHODS

This multicenter prospective observational study of health plan members with symptomatic AFF was conducted using convenience sampling in 7 urban community EDs from 05/2011 to 08/2012. Prospective data collection included presenting symptoms, characteristics of atrial dysrhythmia, ED physician impression of hemodynamic instability, comorbid diagnoses, ED management, and ED discharge rhythm. All centers had full-time on-call cardiology consultation available. Additional variables were extracted from the electronic health record. We identified factors associated with hospitalization and included predictors in a multivariate Poisson Generalized Estimating Equations regression model to estimate adjusted relative risks while accounting for clustering by physician.

RESULTS

Among 1,942 eligible AFF patients, 1,074 (55.3%) were discharged home and 868 (44.7%) were hospitalized. Hospitalization rates ranged from 37.4% to 60.4% across medical centers. After adjustment, modifiable factors associated with increased hospital admission from the ED included non-sinus rhythm at ED discharge, no attempted cardioversion, and heart rate reduction.

DISCUSSION

Within an integrated health system, we found significant variation in AFF hospitalization rates and identified several modifiable factors associated with hospital admission. Standardizing treatment goals that specifically address best practices for ED rate reduction and rhythm control may reduce hospitalizations.

Risk stratification of patients with atrial fibrillation in the emergency department

INTRODUCTION AND METHODS

Early and accurate risk stratification of patients with atrial fibrillation (AF) in the emergency department (ED) could aid the physician in determining a timely treatment strategy appropriate to the severity of disease. We conducted a retrospective review of 243 adult patients who presented to a tertiary ED with AF in 2017. Primary outcome studied was 30-day adverse event (a composite outcome of repeat visit to the ED, cardiovascular complications, and all-cause mortality). Secondary outcome studied was 90-day all-cause mortality. We compared the performance of the RED-AF, AFTER and CHA2DS2-VASc score by plotting receiver operating characteristic (ROC) curves and estimating the areas under curves (AUC), and assessed the potential to further improve the tools with their incorporation of new variables.

RESULTS

Existing scoring tools had poor predictive value for 30-day adverse events, with the RED-AF score performing comparatively better, followed by the AFTER and CHA2DS2-VASc score. All scores performed collectively better to predict 90-day mortality, with the AFTER score performing the best, followed by the RED-AF and CHA2DS2-VASc score. By incorporating heart rate at initial presentation to the ED as a variable into the AFTER Score, we generated a Modified AFTER Score with superior predictive performance above existing scores for 90-day mortality.

CONCLUSION

Existing scores collectively performed poorly to predict 30-day adverse outcomes, but the AFTER and Modified AFTER score showed good predictive value for 90-day mortality. Further studies should be done to validate their use in guiding clinician's disposition of patients with AF in the ED.

Are Rural and Urban Emergency Departments Equally Prepared to Reduce Avoidable Hospitalizations?

INTRODUCTION

Attempts to reduce low-value hospital care often focus on emergency department (ED) hospitalizations. We compared rural and urban EDs in Michigan on resources designed to reduce avoidable admissions.

METHODS

A cross-sectional, web-based survey was emailed to medical directors and/or nurse managers of the 135 hospital-based EDs in Michigan. Questions included presence of clinical pathways, services to reduce admissions, and barriers to connecting patients to outpatient services. We performed chi-squared comparisons, regression modeling, and predictive margins.

RESULTS

Of 135 EDs, 64 (47%) responded with 33 in urban and 31 in rural counties. Clinical pathways were equally present in urban and rural EDs (67% vs 74%, p=0.5). Compared with urban EDs, rural EDs reported greater access to extended care facilities (21% vs 52%, p=0.02) but less access to observation units (52% vs 35%, p=0.04). Common barriers to connecting ED patients to outpatient services exist in both settings, including lack of social support (88% and 76%, p=0.20), and patient/family preference (68% and 68%, p=1.0). However, rural EDs were more likely to report time required for care coordination (88% vs 66%, p=0.05) and less likely to report limitations to home care (21% vs 48%, p=0.05) as barriers. In regression modeling, ED volume was predictive of the presence of clinical pathways rather than rurality.

CONCLUSION

While rural-urban differences in resources and barriers exist, ED size rather than rurality may be a more important indicator of ability to reduce avoidable hospitalizations.

A clinical decision instrument to predict 30-day death and cardiovascular hospitalizations after an emergency department visit for atrial fibrillation: The Atrial Fibrillation in the Emergency Room, Part 2 (AFTER2) study

BACKGROUND

In previous work, we derived and validated a tool that predicts 30-day mortality in emergency department atrial fibrillation (AF) patients. The objective of this study was to derive and validate a tool that predicts a composite of 30-day mortality and return cardiovascular hospitalizations.

METHODS

This retrospective cohort study at 24 emergency departments in Ontario, Canada, included patients with a primary diagnosis of AF who were seen between April 2008 and March 2009. We assessed a composite outcome of 30-day mortality and subsequent hospitalizations for a cardiovascular reason, including stroke.

RESULTS

Of 3,510 patients, 2,343 were randomly selected for the derivation cohort, leaving 1,167 in the validation cohort. The composite outcome occurred in 227 (9.7%) and 125 (10.7%) patients in the derivation and validation cohorts, respectively. Eleven variables were independently associated with the outcome: older age, not taking anticoagulation, HAS-BLED score of ≥3, 3 laboratory results (positive troponin, supratherapeutic international normalized ratio, and elevated creatinine), emergency department administration of furosemide, and 4 patient comorbidities (heart failure, chronic obstructive lung disease, cancer, dementia). In the validation cohort, the observed 30-day outcomes in the 5 risk strata that were defined using the derivation cohort were 2.0%, 6.6%, 10.7%, 12.5%, and 20.0%. The c statistic was 0.73 and 0.69 in the derivation and validation cohort, respectively.

CONCLUSIONS

Using a population-based sample, we derived and validated a tool that predicts the risk of early death and rehospitalization for a cardiovascular reason in emergency department AF patients. The tool can offer information to managing physicians about the risk of death and rehospitalization for AF patients seen in the in emergency department, as well as identify patient groups for future targeted interventions aimed at preventing these outcomes.

Management and Disposition of Atrial Fibrillation in the Emergency Department: A Systematic Review

Introduction

Management of atrial fibrillation (AF) and atrial flutter (AFL) in the emergency department (ED) varies greatly, and there are currently no United States guidelines to guide management with regard to patient disposition after ED treatment. The aim of this systematic review was to evaluate the literature for decision aids to guide disposition of patients with AF/AFLin the ED, and assess potential outcomes associated with different management strategies in the ED.

Methods and Results

A systematic review was done using PubMed (MEDLINE), Cochrane Central Register of Controlled Trials (CENTRAL), and EMBASE, combining the search terms "Atrial Fibrillation", "Atrial Flutter", "Emergency Medicine", "Emergency Service", and "Emergency Treatment". After removal of duplicates, 754 articles were identified. After initial screening of titles and abstracts, 69full text articles were carefully reviewed and 34 articles were ultimately included in the study based on inclusion and exclusion criteria. The articles were grouped into four main categories: decision aids and outcome predictors, electrical cardioversion-based protocols, antiarrhythmic-based protocols, and general management protocols.

Conclusion

This systematic review is the first study to our knowledge to evaluate the optimal management of symptomatic AF/AFLin the ED with a direct impact on ED disposition. There are several viable management strategies that can result in safe discharge from the ED in the right patient population, and decision aids can be utilized to guide selection of appropriate patients for discharge.

Implementation of a Novel Algorithm to Decrease Unnecessary Hospitalizations in Patients Presenting to a Community Emergency Department With Atrial Fibrillation

OBJECTIVES

Atrial fibrillation (AFib) is the most common dysrhythmia in the United States. Patients seen in the emergency department (ED) in rapid AFib are often started on intravenous rate-controlling agents and admitted for several days. Although underlying and triggering illnesses must be addressed, AFib, intrinsically, is rarely life-threatening and can often be safely managed in an outpatient setting. At our academic community hospital, we implemented an algorithm to decrease hospital admissions for individuals presenting with a primary diagnosis of AFib. We focused on lenient oral rate control and discharge home. Our study evaluates outcomes after implementation of this algorithm.

METHODS

Study design is a retrospective cohort analysis pre- and postimplementation of the algorithm. The primary outcome was hospital admissions. Secondary outcomes were 3- and 30-day ED visits and any associated hospital admissions. These outcomes were compared before (March 2013-February 2014) and after (March 2015-February 2016) implementation. Chi-square tests and logistic regressions were run to test for significant changes in the three outcome variables.

RESULTS

A total of 1,108 individuals met inclusion criteria with 586 patients in the preimplementation group and 522 in the postimplementation group. Cohorts were broadly comparable in terms of demographics and health histories. Admissions for persons presenting with AFib after implementation decreased significantly (80.4% pre vs. 67.4% post, adjusted odds ratio [OR] = 3.4, p < 0.001). Despite this difference there was no change in ED return rates within 3 or 30 days (adjusted ORs = 0.93 and 0.89, p = 0.91 and 0.73, respectively).

CONCLUSIONS

Implementation of a novel algorithm to identify and treat low-risk patients with AFib can significantly decrease the rate of hospital admissions without increased ED returns. This simple algorithm could be adopted by other community hospitals and help lower costs.

Measuring Emergency Department Acuity

BACKGROUND

Emergency department (ED) acuity is the general level of patient illness, urgency for clinical intervention, and intensity of resource use in an ED environment. The relative strength of commonly used measures of ED acuity is not well understood.

METHODS

We performed a retrospective cross-sectional analysis of ED-level data to evaluate the relative strength of association between commonly used proxy measures with a full spectrum measure of ED acuity. Common measures included the percentage of patients with Emergency Severity Index (ESI) scores of 1 or 2, case mix index (CMI), academic status, annual ED volume, inpatient admission rate, percentage of Medicare patients, and patients seen per attending-hour. Our reference standard for acuity is the proportion of high-acuity charts (PHAC) coded and billed according to the Centers for Medicare and Medicaid Service's Ambulatory Payment Classification (APC) system. High-acuity charts included those APC 4 or 5 or critical care. PHAC was represented as a fractional response variable. We examined the strength of associations between common acuity measures and PHAC using Spearman's rank correlation coefficients (r_s ) and regression models including a quasi-binomial generalized linear model and linear regression.

RESULTS

In our univariate analysis, the percentage of patients ESI 1 or 2, CMI, academic status, and annual ED volume had statistically significant associations with PHAC. None explained more than 16% of PHAC variation. For regression models including all common acuity measures, academic status was the only variable significantly associated with PHAC.

CONCLUSION

Emergency Severity Index had the strongest association with PHAC followed by CMI and annual ED volume. Academic status captures variability outside of that explained by ESI, CMI, annual ED volume, percentage of Medicare patients, or patients per attending per hour. All measures combined only explained only 42.6% of PHAC variation.

Association of atrial fibrillation risk alleles and response to acute rate control therapy

OBJECTIVES

Given the sparse evidence for selection of first-line therapy for acute atrial fibrillation (AF) based on clinical factors alone, incorporation of genotype data may improve the effectiveness of treatment algorithms and advance the understanding of interpatient heterogeneity. We tested whether candidate nucleotide polymorphisms (SNPs) related to AF physiologic responses are associated with ventricular rate control after intravenous diltiazem in the emergency department (ED).

METHODS

We conducted an analysis within a prospective observational cohort of ED patients with acute symptomatic AF, ventricular rate >110 beats per minute within the first 2 hours, initially treated with intravenous diltiazem, and who had DNA available for analysis. We evaluated 24 candidate SNPs that were grouped into 3 categories based on their phenotype response (atrioventricular nodal [AVN] conduction, resting heart rate, disease susceptibility) and calculated 3 genetic scores for each patient. Our primary outcome was maximum heart rate reduction within 4 hours of diltiazem administration. Multivariable regression was used to identify associations with the outcome while adjusting for age, sex, baseline heart rate, and diltiazem dose.

RESULTS

Of the 142 patients, 127 had complete data for the primary outcome. None of the genetic scores for AVN conduction, resting heart rate, or AF susceptibility showed a significant association with maximal heart rate response.

CONCLUSION

Using a candidate SNP approach, screening for genetic variants associated with AVN conduction, resting heart rate, or AF susceptibility failed to provide significant data for predicting successful rate control response to intravenous diltiazem for treating acute AF in the ED.

Thirty-day mortality in ED patients with new onset atrial fibrillation and actively treated cancer

OBJECTIVES

Studies suggest that inflammatory, autonomic, and coagulation alterations associated with cancer may increase incident atrial fibrillation (AF). New-onset AF is associated with increased mortality in other nonneoplastic disease processes. We investigated the association of active cancer with 30-day mortality in emergency department (ED) patients with new-onset AF.

METHODS

We conducted an analysis within an observational cohort study at a tertiary care hospital that included ED patients with new-onset AF. The exposure variable was presence of active cancer. We defined active cancer as the patient received chemotherapy, radiotherapy, or recent cancer-related surgery within 90 days of the ED visit. The primary outcome was 30-day mortality. Logistic regression was used to analyze the association between cancer status and 30-day mortality adjusting for patient age and sex.

RESULTS

During the 5.5-year study period, 420 patients with new-onset AF were included in our cohort, including 37 (8.8%) with active cancer. Patients with active cancer had no clinically relevant differences in their hemodynamic stability. Among the 37 patients with active cancer, 9 (24%) died within 30 days. Of the 383 patients without active cancer, 11 (3%) died within 30 days. After adjusting for age and sex, active cancer was an independent predictor of 30-day mortality, with an adjusted odds ratio of 10.8 (95% confidence interval, 3.8-31.1).

CONCLUSIONS

Among ED patients with new-onset AF, active cancer appears to be associated with 11-fold increased odds of 30-day mortality; new-onset AF may represent progressive organ dysfunction leading to an increased risk of short-term mortality in patients with cancer.