Anticoagulation prescription among atrial fibrillation patients managed with and without an anticoagulant initiation pathway: a cohort study.

BACKGROUND AND IMPORTANCE: The Canadian Association of Emergency Physicians atrial fibrillation (AF) checklist advises that emergency physicians initiate anticoagulation therapy for patients with AF or flutter who are CHADS65 positive. OBJECTIVES: The aim was to compare anticoagulation initiation rates between patients treated with and without an anticoagulation assessment pathway (the SAFE pathway). DESIGN: This was a retrospective cohort study. SETTINGS AND PARTICIPANTS: All emergency department patients were discharged home with a diagnosis of AF between June 2018 and May 2020 at two Canadian emergency departments. INTERVENTION: The SAFE pathway is a hard copy form which allows emergency physicians to document contraindications to anticoagulation, the positive components of the CHADS65 score, and details how to prescribe anticoagulation. OUTCOME MEASURES AND ANALYSIS: Trained researchers abstracted data on the use of the SAFE pathway by the presence or absence of the completed, scanned pathway in the electronic medical chart. The exposure of interest was use of this pathway. Patients were followed forward in time for 90 days by electronic medical record review to document stroke, transient ischemic attack, arterial embolism and major bleeding events. All events were independently adjudicated. Adjusted odds ratios were calculated to compare outcomes between those managed with and without the SAFE pathway. RESULTS: In total, 766 patients were included, of whom 264 were already taking anticoagulation, 166 were CHADS65 negative and 65 had a contraindication to anticoagulation, leaving 271 patients eligible for anticoagulation prescription. Among the 271 eligible patients, 137/166 managed with the SAFE pathway were initiated on anticoagulation and 24/105 managed without the SAFE pathway started anticoagulation (adjusted odds ratio 25.9; 13.1-51.2). There was no statistically significant difference in the 90-day rate of stroke or bleeding. CONCLUSION: Use of the SAFE pathway was associated with a higher rate of anticoagulation prescription.

Anticoagulation for newly diagnosed atrial fibrillation and 90-day rates of stroke and bleeding.

BACKGROUND: Atrial fibrillation increases the risk of stroke, which can be mitigated by anticoagulant prescription. We evaluated local emergency physician anticoagulation practice for patients discharged from the emergency department with atrial fibrillation, along with 90-day incidence of stroke and major bleeding. METHODS: This was a health record review of patients diagnosed with new onset atrial fibrillation in two emergency departments between 2014 and 2017. We collected data on CHADS65 scores, contraindications to direct oral anticoagulant (DOAC) prescription and initiation of anticoagulation in the ED. Patient charts were reviewed for the diagnosis of stroke, transient ischemic attack (TIA), systemic embolism or major bleeding within 90 days. RESULTS: We identified 399 patients, median age 68 (IQR 57-79), 213 (53%) male. Only 299/399 patients had an indication for anticoagulation (CHADS65-positive). Of these 299, 27 had a contraindication to or were already prescribed anticoagulation. 45/272 (17%, 95% confidence interval 12-22%) patients eligible for initiation of anticoagulation left the emergency department with a prescription for anticoagulation. During 90-day follow-up, seven patients had stroke or TIA. Four stroke/TIA patients had been eligible to start an anticoagulant but were not started, two left the emergency department with prescriptions for an anticoagulant and one patient had a contraindication to initiating anticoagulation in the emergency department. There were no major bleeding episodes. CONCLUSION: Few eligible patients were prescribed anticoagulation and the 90-day stroke rate was high. Physicians should become familiar with the CAEP Acute AF Best Practices Checklist AF which offers guidance on anticoagulation prescription.

RéSUMé: CONTEXTE: La fibrillation auriculaire augmente le risque d'accident vasculaire cérébral, qui peut être atténué par la prescription d'anticoagulants. Nous avons évalué la pratique d'anticoagulation des médecins d'urgence locaux pour les patients sortis du service d'urgence avec la fibrillation auriculaire, ainsi que l'incidence sur 90 jours d'AVC et des saignements majeurss. MéTHODES: Il s'agissait d'un examen du dossier de santé des patients diagnostiqués avec une nouvelle apparition de la fibrillation auriculaire dans deux services d'urgence entre 2014 et 2017. Nous avons recueilli des données sur les scores CHADS65, les contre-indications à la prescription d'anticoagulants oraux directs (AOD) et l'initiation de l'anticoagulation au service des urgences. Les fiches des patients ont été revues pour le diagnostic d'AVC, d'accident ischémique transitoire (AIT), d'embolie systémique d'hémorragie majeure dans les 90 jours. RéSULTATS: Nous avons identifié 399 patients, d'âge médian 68 (IQR 57-79), 213 (53 %) hommes. Seuls 299/399 patients avaient une indication d'anticoagulation (CHADS65 positif). Sur ces 299, 27 présentaient une contre-indication ou se voyaient déjà prescrire une anticoagulation. 45/272 (17 %, 95 % intervalle de confiance de 12 % à 22 %) patients éligibles pour l'initiation de l'anticoagulation ont quitté avec une prescription d'anticoagulation. Au cours du suivi de 90 jours, sept patients ont eu un accident vasculaire cérébral ou un AIT. Quatre patients ayant subi un AVC / AIT étaient éligibles pour commencer un anticoagulant mais qui n'ont pas été commencés, deux ont quitté le service des urgences avec des ordonnances d'un anticoagulant et un patient avait une contre-indication à l'initiation de l'anticoagulation au service des urgences. Il n'y a pas eu d'épisodes d'hémorragie majeure. CONCLUSION: Peu de patients éligibles se sont vu prescrire une anticoagulation et le taux d'AVC durant les 90 jours était élevé. Les médecins doivent se familiariser avec la liste de contrôle des meilleures pratiques pour la CAEP FA aiguë qui offre des conseils sur la prescription des anticoagulations.

Feasibility of a quality improvement project to increase adherence to evidence-based pulmonary embolism diagnosis in the emergency department.

BACKGROUND: Many evidence-based clinical decision tools are available for the diagnosis of pulmonary embolism (PE). However, these clinical decision tools have had suboptimal uptake in the everyday clinical practice in emergency departments (EDs), despite numerous implementation efforts. We aimed to test the feasibility of a multi-faceted intervention to implement an evidence-based PE diagnosis protocol. METHODS: We conducted an interrupted time series study in three EDs in Ontario, Canada. We enrolled consecutive adult patients accessing the ED with suspected PE from January 1, 2018, to February 28, 2020. Components of the intervention were as follows: clinical leadership endorsement, a new pathway for PE testing, physician education, personalized confidential physician feedback, and collection of patient outcome information. The intervention was implemented in November 2019. We identified six criteria for defining the feasibility outcome: successful implementation of the intervention in at least two of the three sites, capturing data on ≥ 80% of all CTPAs ordered in the EDs, timely access to electronic data, rapid manual data extraction with feedback preparation before the end of the month ≥ 80% of the time, and time required for manual data extraction and feedback preparation ≤ 2 days per week in total. RESULTS: The intervention was successfully implemented in two out of three sites. A total of 5094 and 899 patients were tested for PE in the period before and after the intervention, respectively. We captured data from 90% of CTPAs ordered in the EDs, and we accessed the required electronic data. The manual data extraction and individual emergency physician audit and feedback were consistently finalized before the end of each month. The time required for manual data extraction and feedback preparation was ≤ 2 days per week (14 h). CONCLUSIONS: We proved the feasibility of implementing an evidence-based PE diagnosis protocol in two EDs. We were not successful implementing the protocol in the third ED. REGISTRATION: The study was not registered.