Improving Emergency Department Prescribing of Anticoagulation for Atrial Fibrillation Through an Iterative Quality Improvement Process

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Atrial fibrillation (n=1425). Intervention: Targeted anticoagulation guidance within an emergency department atrial fibrillation clinical pathway vs. Pre-pathway standard emergency department care. Primary outcome: Proportion of patients discharged from the emergency department on any anticoagulation (p=2 × 10−16).

Finn Brokenshire; Kaleb Addy; John William Pickering; Ibrahim Saleh Al-Busaidi; Martin Paul Than; Richard William Troughton; Laura R Joyce

doi:10.1111/1742-6723.70097

July 11, 2025Emergency Medicine AustralasiaOpen Access

Improving Emergency Department Prescribing of Anticoagulation for Atrial Fibrillation Through an Iterative Quality Improvement Process

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Key result

An ED atrial fibrillation pathway is linked to ~39 percentage points higher discharge anticoagulation prescribing.

P=2 × 10−16
n=1,425

Why the study?

The impact of two iterations of an emergency department AF pathway with targeted anticoagulation guidance on anticoagulant prescribing needed assessment.

Does targeted anticoagulation guidance within an emergency department atrial fibrillation pathway improve anticoagulant prescribing rates on discharge without increasing adverse events in patients presenting with isolated atrial fibrillation?

Key Points

To assess the effect of two iterations of an emergency department atrial fibrillation pathway with targeted prescribing guidance on anticoagulant prescription rates.
Monitored anticoagulation prescribing rates across four cohorts of patients presenting with isolated atrial fibrillation over a 9-year period from 2014 to 2023 (N=1425) at a single emergency department.
Implemented iterative pathway guidance, evolving from risk scoring (CHA2DS2-VASc and HAS-BLED) to targeted clinician guidance specifying direct oral anticoagulants, particularly rivaroxaban.
The proportion of patients discharged from the emergency department on anticoagulation increased from 44.7% (46/103) pre-pathway to 83.4% (302/362) in the final cohort (chi-squared = 103, df = 3, p = 2 × 10^-16).
Direct oral anticoagulants accounted for 95.0% (287/302) of discharge anticoagulation in the final cohort, shifting predominantly to rivaroxaban.
Sixty-day adverse outcomes remained low across cohorts, with no significant change in thromboembolic events, bleeding events, or all-cause mortality.

Study Design

Type

Cohort (n=1,425)

Multicenter

No

Structured PICO

Does targeted anticoagulation guidance within an emergency department atrial fibrillation pathway improve anticoagulant prescribing rates on discharge without increasing adverse events in patients presenting with isolated atrial fibrillation?

P

Population

1,425 patients (median age 66-70 years, 50.7% female) presenting to a New Zealand emergency department with isolated atrial fibrillation across four cohorts from 2014 to 2023, followed for 60 days.

I

Intervention

Two iterations of an emergency department atrial fibrillation clinical pathway ('rate-and-wait' approach) providing targeted anticoagulation guidance: initially suggesting calculation of CHA2DS2-VASc and HAS-BLED scores to guide prescribing, and later altered to direct prescription of rivaroxaban once daily for 5 days on ED discharge (unless contraindicated) with community follow-up to determine longer-term use.

C

Comparator

Pre-pathway management (2014–2015 cohort, prior to the introduction of an ED-specific pathway for AF management) and earlier pathway iterations.

O

Outcome

Proportion of patients discharged from the emergency department on any anticoagulation.surrogate

Main Result

Absolute Event Rate: 83.4% vs 44.7%

p-value: p=2 × 10−16

Implementing directive anticoagulation guidance (specifically 5-day discharge packs of rivaroxaban with community follow-up) within an emergency department atrial fibrillation pathway substantially increased discharge anticoagulation rates from 45% to 83% without increasing 60-day bleeding or mortality.

Limitations

Sample size and incidence of ischaemic stroke were too small to detect any change in ischaemic stroke rates.
Single-center study; a larger multi-centre trial would be required to assess changes in stroke rates.
Clinician willingness to anticoagulate may have been confounded by the increasing general availability and perceived ease of initiating DOACs compared to warfarin.
Identification of 60-day adverse events was limited to hospital re-presentations within the South Island of New Zealand, potentially missing mild events managed in the community or hospital visits outside the region.
Sample size and incidence of ischaemic stroke were too small to show any change in ischaemic stroke rates.
Willingness to anticoagulate may have been confounded by increasing general use of DOACs perceived as less burdensome than warfarin.
Identification of adverse events was limited to hospital re-presentations within the South Island of New Zealand, potentially missing mild adverse events managed out of hospital or visits outside the region.

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Answers are grounded in this paper and cite their sources.

Implication

May support ED AF pathways with anticoagulation guidance; leaves open whether randomized trials confirm net clinical benefit.

Abstract

Objective To assess the impact of two iterations of an emergency department (ED) atrial fibrillation (AF) pathway on anticoagulant prescribing. Methods Two quality improvement projects gave targeted anticoagulation guidance for AF. Anticoagulation prescription rates and related adverse events were monitored across four cohorts over 9 years (2014–2023). Results A total of 1425 patients were included. The proportion of patients discharged from ED on anticoagulation increased from 45% to 83%. Sixty‐day thromboembolic events, bleeding events and all‐cause mortality were unchanged. Conclusions Targeted anticoagulation guidance within an AF pathway improved adherence without raising adverse events.

Discussion

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Cite This Study

Brokenshire et al. (2025) conducted a cohort in Atrial fibrillation (n=1,425). Targeted anticoagulation guidance within an emergency department atrial fibrillation clinical pathway vs. Pre-pathway standard emergency department care was evaluated on Proportion of patients discharged from the emergency department on any anticoagulation (p=2 × 10−16). Targeted anticoagulation guidance within an emergency department AF pathway increased anticoagulation prescribing at discharge from 45% to 83% (p = 2 × 10−16) without increasing 60-day adverse events.

synapsesocial.com/papers/6aea46c5acacf316c8f67d69 https://doi.org/10.1111/1742-6723.70097

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Improving Emergency Department Prescribing of Anticoagulation for Atrial Fibrillation Through an Iterative Quality Improvement Process

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Improving Emergency Department Prescribing of Anticoagulation for Atrial Fibrillation Through an Iterative Quality Improvement Process

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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