Atrial fibrillation patients presenting to an emergency department successfully managed with a next-day community follow-up pathway: A before-and-after cohort study
Finn Brokenshire, John W Pickering BMedSc(Hons), PhD, BA(Hons), Ibrahim S Al-Busaidi FRNZCGP, MBChB, BMedSc(Hons), PGDip Obesity Weight Management, Martin Than FACEM, MBBS, Richard Troughton MBChB, PhD, Kaleb Addy MBChB, Laura R Joyce FACEM, AFRACMA, MBChB, BMedSc(Hons), MMedEd
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引用次数: 0
Abstract
Objectives
To assess the effectiveness and safety of the new clinical pathway for patients presenting to an ED with AF, incorporating community next-working-day follow-up and more specific clinician guidance around medication prescribing.
Methods
A before-and-after, retrospective cohort study comparing patients presenting to Christchurch ED with acute uncomplicated AF in the year before (‘hospital-based’ follow-up) and after (‘community-based’ follow-up) implementation of a new AF management approach. The ‘community’ pathway replaced hospital-based review with a next-day community follow-up and introduced more specific anticoagulation recommendations.
Results
A total of 1065 patients met inclusion criteria, with 531 presenting during the ‘hospital-based’ pathway period and 534 during the ‘community’ pathway period. The spontaneous reversion rate was approximately 61% in both cohorts. Following the implementation of the community pathway, there was no increase in cardioversions (16.6% vs 20%, difference 3.5% [95% CI −1.4 to 8.3]), admission rates (32.8% vs 32.2%, difference − 0.6% [95% CI −6.4 to 5.3]), or AEs (60-day all-cause mortality 1.3% vs 0.9%, difference − 0.7% [95% CI −2.3 to 1]). Attendance at a follow-up AF clinic improved from 92.9% to 98.1% (difference 5.2% [95% CI 0.7–9.7]). Clinician adherence to anticoagulation guidelines increased by 7% (95% CI 1.6–12.4).
Conclusions
A ‘rate-and-wait’ strategy for managing acute uncomplicated AF continues to allow a significant proportion of patients to self-revert to sinus rhythm, without requiring hospital admission or cardioversion procedures. Transitioning to an off-site, community AF clinic is both safe and effective, demonstrating increased clinic attendance and improved adherence to anticoagulation guidelines.
目的评估新的临床途径对急诊科合并房颤患者的有效性和安全性,并结合社区次日随访和更具体的临床医生用药指导。方法一项前后回顾性队列研究,比较克赖斯特彻奇ED患者在实施新的房颤管理方法前(“基于医院的”随访)和后(“基于社区的”随访)一年出现急性无并发症房颤的患者。“社区”途径用第二天的社区随访取代了以医院为基础的审查,并引入了更具体的抗凝建议。结果1065例患者符合纳入标准,其中531例在“以医院为基础”的途径期出现,534例在“社区”的途径期出现。在两个队列中,自发恢复率约为61%。实施社区途径后,转复率(16.6% vs 20%,差异3.5% [95% CI−1.4 ~ 8.3])、入院率(32.8% vs 32.2%,差异0.6% [95% CI−6.4 ~ 5.3])或ae(60天全因死亡率1.3% vs 0.9%,差异0.7% [95% CI−2.3 ~ 1])均未增加。房颤门诊随访出勤率从92.9%提高到98.1%(差异5.2% [95% CI 0.7-9.7])。临床医生对抗凝指南的依从性增加了7% (95% CI 1.6-12.4)。结论:治疗急性无并发症房颤的“率-等待”策略继续允许很大比例的患者自我恢复窦性心律,无需住院或心脏复律程序。过渡到非现场的社区房颤诊所既安全又有效,表明增加了诊所出勤率,并改善了抗凝指南的依从性。
期刊介绍:
Emergency Medicine Australasia is the official journal of the Australasian College for Emergency Medicine (ACEM) and the Australasian Society for Emergency Medicine (ASEM), and publishes original articles dealing with all aspects of clinical practice, research, education and experiences in emergency medicine.
Original articles are published under the following sections: Original Research, Paediatric Emergency Medicine, Disaster Medicine, Education and Training, Ethics, International Emergency Medicine, Management and Quality, Medicolegal Matters, Prehospital Care, Public Health, Rural and Remote Care, Technology, Toxicology and Trauma. Accepted papers become the copyright of the journal.