Novel ER Treatment Protocol for AF Cuts Admissions, Hospital Length of Stay

May 18, 2015

BOSTON, MA — A novel, multidisciplinary treatment protocol that adheres to "best practices" for the management of atrial-fibrillation patients in the emergency department significantly reduced hospital admission rates and hospital length of stay, according to the results of a new study[1].

"Each physician or emergency-room provider treats [atrial-fibrillation] patients in different ways," senior investigator Dr Moussa Mansour (Massachusetts General Hospital, Boston) told heartwire from Medscape. "Some patients get admitted, some patients go home. There is no standardized way of treating patients with atrial fibrillation who come to the emergency room. As a result, a significant number of patients end up being admitted to the hospital."

With the lack of standardization, Mansour said their hospital established a collaborative-care protocol that included physicians in the departments of emergency medicine, electrophysiology, and anesthesiology. The treatment protocol included the early use of the electrophysiologist, an expedited pathway for cardioversion in appropriate patients, and the use of novel oral anticoagulants to simplify the initiation of anticoagulation.

In presenting the results of the study at the Heart Rhythm Society (HRS) 2015 Scientific Sessions, Mansour said the treatment protocol adhered to society guidelines for the treatment of atrial fibrillation. "The protocol," he said, "ensured that patients were able to get home instead of being at the hospital. That's beneficial to the hospital and beneficial to the patient."

Over a 1-year period, there were 382 patients treated in the emergency department for atrial fibrillation. Patients treated according to the collaborative pathway were significantly less likely to be admitted to the hospital compared with historical controls (15% vs 79%, P<0.01). Among those who were admitted, the mean hospital length of stay was significantly shorter among patients who were treated according to the protocol (32.4 hours vs 88.9 hours, P=0.004). Importantly, normal sinus rhythm was restored in 87% of patients treated according to algorithm vs 65% of patients who were not.

To heartwire , Mansour said the treatment protocol involves assessing the stability of the patient and ruling out secondary causes of atrial fibrillation such as infection or thyroid disease. For stable patients with atrial fibrillation as the primary diagnosis, the patient is enrolled in the treatment pathway, with physicians assessing whether to treat with rhythm or rate control and then providing appropriate care.

Although the researchers did not evaluate the cost savings of the protocol, the reduction in hospital admissions is a surrogate end point suggestive of cost savings with the treatment algorithm, said Mansour. However, "the main gain is to make sure that patients are treated according to the newest guidelines from guidelines such as the Heart Rhythm Society," said Mansour. "We hope this is something other hospitals will use as well."

Mansour reports consulting fees/honoraria from Biosense Webster and SentreHEART and research grants from St Jude Medical, Biosense Webster, and Boston Scientific. Disclosures for the coauthors are listed in the abstract.

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