Objectives & Background Atrial Fibrillation (AF) is a common presentation to the Emergency Department. However there is marked inconsistency in how patients are managed.
Professor Mark Baker, NICE's Director of Clinical Practice: “AF increases the risk of strokes by up to five times. It's estimated that the condition causes around 12,500 strokes each year…. Unfortunately only half of those who should be getting these drugs (anticoagulants), are. This needs to change.”
An audit of practice in December 2015 UHS ED revealed that only 10% had any documented stroke risk stratification.
The aims of our Quality Improvement Project were:
▸ To provide a standardised, evidence based approach to the management of newly diagnosed AF in UHS ED.
▸ Reduce the admission rate of patients attending ED with AF.
▸ Improve patient safety by ensuring patients are appropriately risk stratified and anticoagulated.
Methods ▸ Review of literature and current guidelines. NICE 2014, ESC 2012, AHA 2014. We created a pragmatic and evidence based ‘Management of AF Pathway' agreed by ED/Cardiology/Pharmacy and Governance leads. The pathway went through several PDSA cycles.
▸ We created process maps looking at the journey of patients with AF to identify delays in investigation, diagnosis and treatment. If patients with new AF are treated in a timely manner successful rate/rhytm control can be achieved in a greater proportion within 4 hrs and therefore discharged with follow up.
▸ Clinician education and clear guidance with regard to risk stratification and anticoagulation.
Results The results of this QuIP are:
▸ A locally agreed, evidence based approach to the management of newly diagnosed AF.
Outcome 2 and 3 are represented by Run Charts demonstrating Discharge Rate over time and Risk Stratification/anticoagulation over time.
▸ Admission rates fluctuated around 60%. There was no significant change after implementation of changes.
▸ There was a huge change in numbers of patients risk stratified/anticoagulated. The initial rate was 10% increasing to 85% in the most recent data collected.
Conclusion The management of AF is complex. However it is possible to create and implement a locally agreed, evidence based guideline which is well received by both ED physicians and Cardiology. We have demonstrated a marked improvement in stroke risk stratification/anticoagulation and therefore impacted on patient safety.⇓
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