Adoption of a single-page best practice algorithm improves outcomes in patients with acute atrial fibrillation: a multi-disciplinary quality improvement project

Abstract

Introduction: In response to a serious incident involving an atrial fibrillation (AF) associated stroke, a quality improvement project was established to examine and improve all aspects of patient care for individuals presenting with acute AF to London’s North Middlesex University Hospital (NMUH).Materials and Methods: The presenting complaint was examined for 2,105 consecutive medical admissions to identify 100 patients (4.7%) with acute AF. For each patient, 36 indices and performance indicators were collected and analysed against international standards. Deficiencies were identified in documentation, risk stratification, anticoagulation and arrhythmia management decisions. With cross-specialty collaboration, a single-page AF management algorithm was established using sequential PDSA methodology, and a further 100 consecutive patients with acute AF were analysed prospectively. A composite end-point of adverse outcomes (AF-associated readmission, stroke, cardiac death or major bleeding) was examined.Results: Algorithm implementation significantly reduced the proportion of patients exposed to unnecessary stroke risk (30% vs 4%, p<0.0001); improved identification and documentation of thromboembolic potential (50% vs 88%, p<0.0001), reduced incorrect drug decisions (12% vs 2%, p=0.01), reduced contraindicated rhythm control (8% vs 0%, p=0.007), and increased direct oral anticoagulant (DOAC) prescribing (38% vs 86%, p<0.0001) over warfarin. After a mean follow-up of 248 +/- 91 days, there was a significant reduction in composite adverse outcomes (22% vs 6%, p=0.0018).Conclusion: Using established quality improvement methodology and cost-neutral multi-disciplinary expertise, this novel management algorithm has significantly improved the quality and safety of care for patients with acute AF at NMUH.