Impact of a Multidisciplinary Treatment Pathway for Atrial Fibrillation in the Emergency Department on Hospital Admissions and Length of Stay: Results of a Multi‐Center Study

Figures

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  Figure 1. Diagram of the multidisciplinary AF treatment pathway. Prompt cardiac electrophysiology (EP) consultation was obtained for all enrolled patients. This was followed by discussion between the EP and emergency medicine (EM) clinicians to determine the appropriate treatment strategy (rhythm vs rate control). If a rhythm control strategy was chosen, the EP team assisted in expediting cardioversion. The EP team also assisted in the choice of the most appropriate anticoagulant irrespective of the choice of rhythm or rate control strategy. The EP and EM clinicians then assessed the patient's response to therapy and determined the patient's candidacy for discharge from the emergency department (ED). AF indicates atrial fibrillation; NOAC, novel oral anticoagulant; TEE, transesophageal echocardiography.

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  Figure 2. Design of the multicenter, prospective, 2‐stage study of the AF treatment pathway. All patients presenting with AF to the ED at both participating institutions were screened for inclusion in the study. Patients were enrolled if they presented with AF as a primary problem, met the inclusion criteria, and did not meet the exclusion criteria. In stage 1 of the study, enrolled patients received routine care. In stage 2 of the study, enrolled patients were treated according to the AF pathway, as described in Figure 1. At the conclusion of the study, impact of the AF pathway on the primary and secondary study outcomes was determined. AF indicates atrial fibrillation; ED, emergency department; LOS, length of stay; OAC, oral anticoagulant.

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  Figure 3. Impact of AF pathway utilization on inpatient admission rate and length of stay (LOS). A, Bar graph that describes hospital admission rates in the routine care and AF treatment pathway cohorts. Significantly fewer patients treated according to the AF pathway were admitted to an inpatient unit (P<0.001). B, Box plots that describe total hospital LOS (ED LOS plus inpatient LOS) for patients who were admitted from the ED to an inpatient unit. Box limits represent the first and third quartiles. The line within the box represents the median value. Whiskers represent the most extreme data points that are not more than 1.5 times the length of the box away from the box border. Circles represent outlier data points. Mean hospital LOS was significantly shorter for patients treated according to the AF pathway (P=0.01). C, Box plots that describe ED LOS for all patients, irrespective of admission status. Format of the box plots is the same as displayed in (B). There was not a statistically significant difference in time spent in the ED for the 2 study cohorts (P=0.32). AF indicates atrial fibrillation; ED, emergency department.

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  Figure 4. Kaplan–Meier estimate of the probability of discharge for patients in the AF pathway and routine care cohorts. Probability of discharge as a function of time after arrival in the ED was calculated for all patients in both study cohorts. Kaplan–Meier curves for the AF pathway and routine care cohorts reveal a significantly higher probability of discharge for patients treated according to the AF pathway (P<0.001). AF indicates atrial fibrillation; ED, emergency department.