Novel Care Pathway for Patients Presenting to the Emergency Department With Atrial Fibrillation
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Goals and Visions of the Program
The annual cost of care for atrial fibrillation (AF) is estimated to be $6.65 billion, with nearly three fourth of costs because of hospitalizations1 and 70% of admissions present through the emergency department (ED).2 In an international survey of routine ED AF management from Canada, United States, United Kingdom, and Australia, there were striking differences in ED use of rate control or rhythm control interventions and the likelihood of discharge.3 For example, in Canada, the vast majority of patients with AF in the ED are pharmacologically or electrically cardioverted without cardiology supervision. In the United States, the majority of patients are admitted for further management. Several small US studies have evaluated the use of an ED observation unit with a protocol for pharmacological or direct current cardioversion in selected patients.4 However, these studies often rely on specialist consultation in the ED and do not rely heavily on outpatient care coordination, which are critical for improving quality of care. In 2011, the Center for Innovation in Complex Care assessed gaps in care for patients presenting to the health system with AF; identified gaps included a lack of standardization, integration, and information access across the various providers—including ED centers, cardiologists, primary care specialists, nurses, and pharmacists—who comanage AF patients.5
To address some of these problems in AF management, the goal of this innovation was to introduce a structured process for AF care, linking the expertise of ED and cardiology practices with the introduction of clinical pharmacists to bridge the gap and coordinate treatment, to reduce unnecessary hospital admissions while improving access to comprehensive AF care.
Local Challenges in Implementation
According to the Agency for Healthcare Research and Quality, in 2012, hospitalizations associated with the diagnosis of AF in North Carolina accounted for >110 000 patient discharges, and ≈15 000 encounters in which AF …