• Saman Rezazadeh, Derek S Chew, Miller Robert J H RJH *Libin Cardiovascular Institute of Alberta,Department of Cardiac Sciences,University of Calgary,Calgary,AB., Sheila Klassen, Payam Pournazari, Graham Bennett, Eddy Lang, and F Russell Quinn.
• *Libin Cardiovascular Institute of Alberta,Department of Cardiac Sciences,University of Calgary,Calgary,AB.
• Can J Emerg Med. 2018 Nov 1; 20 (6): 841-849.

ObjectiveOral anticoagulation (OAC) reduces stroke risk in patients with atrial fibrillation (AF) or atrial flutter (AFL). However, OAC initiation rates in patients discharged directly from the emergency department (ED) are low. We aimed to address this care gap by implementing a quality improvement intervention.MethodsThe study was performed in four Canadian urban EDs between 2015 and 2016. Patients were included if they had an electrocardiogram (ECG) documenting AF/AFL in the ED, were directly discharged from the ED, and were alive after 90 days. Baseline rates of OAC initiation were determined prior to the intervention. Between June and December 2016, we implemented our intervention in two EDs (ED-intervention), with the remaining sites acting as controls (ED-control). The intervention included a reminder statement prompting OAC initiation according to guideline recommendations, manually added to ECGs with a preliminary interpretation of AF/AFL, along with a decision-support algorithm that included a referral sheet. The primary outcome was the rate of OAC initiation within 90 days of the ED visit.ResultsPrior to the intervention, 37.2% OAC-naïve patients with ECG-documented AF/AFL were initiated on OAC. Following implementation of the intervention, the rate of OAC initiation increased from 38.6% to 47.5% (absolute increase of 8.5%; 95% CI, 0.3% to 16.7%, p=0.04) among the ED-intervention sites, whereas the rate remained unchanged in ED-control sites (35.3% to 35.9%, p=0.9).ConclusionsImplementation of a quality improvement intervention consisting of a reminder and decision-support tool increased initiation of OAC in high-risk patients. This support package can be readily implemented in other jurisdictions to improve OAC rates for AF/AFL.

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