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University of North Carolina Health Care

Optimizing the Management of Patients Presenting to the Emergency Department with Atrial Fibrillation: Pharmacists at the Center of a New Treatment Paradigm

Zack Deyo, Pharm.D., BCPS, CPP; Leah Hatfield, Pharm.D., BCPS; Phil Mendys, Pharm.D., FAHA CPP; Heather Tuttle, B.S.N., R.N., CEN; Jennifer Walker, M.S.N., ANP-BC; Kevin Biese, M.D., MA.T.; Anil Gehi, M.D.

University of North Carolina Health Care, Chapel Hill, North Carolina

Atrial Fibrillation (AF) is the most common cardiac dysrhythmia in adults, affecting an estimated 2-3 million Americans and growing to near epidemic proportions. The annual cost of care for AF is estimated to be $6.65 billion with nearly ¾ of this due to the cost of hospitalization. Over 70% of AF admissions enter the health-care system through the Emergency Department (ED).

There are limited best practices and quality data to guide the management of AF patients who present to the ED. Evidence suggests that a holistic, multidisciplinary approach may be beneficial. Pharmacists embedded in the ED and outpatient clinics at our institution are the common link in the transition of care between the ED and clinic.

We engaged the expertise of Cardiology and Emergency Medicine to develop a triage protocol to risk stratify patients presenting to the ED with AF based on hemodynamic stability and symptom severity into low, moderate, or high risk categories. We created clinic note templates to assess stroke risk, symptoms, and control of key risk factors.  Patient education materials focused on risk reduction and self-care during AF. An operational workflow delineated roles and provided a clear plan for after-hours consultation and scheduling. We hypothesized that by using this structured process we could reduce unnecessary hospital admission and improve the quality of AF care.

Between January and June 2015, 100 patients presented to our ED with a primary diagnosis of AF. Of these, 81 were admitted to the hospital with an average length of stay of 3.0-days. Following implementation of the care pathway, between July 2015 and March 2016, 98 patients presented to our ED with a primary diagnosis of AF. Fifty-six patients were admitted and 42 discharged from the ED, 37 of whom followed up in the AF Transitions Clinic. The average length of stay was 2.5-days. The admission rate was reduced from 81.0% pre-implementation to 57.1% post-implementation (p<0.001). The mean time to clinic visit was 3 days with 67.8% seen in 24-48 hours. Re-presentation to the ED with a primary diagnosis of AF at 90 days was not significantly increased (1 patient pre-implementation vs 2 patients post-implementation).

We successfully implemented a novel care pathway to triage and discharge AF patients from the emergency department with closed-loop follow up with a clinical pharmacist that dramatically changed practice in our health-system. This highlights the role of pharmacists in the ED and clinic functioning as advanced practice providers delivering AF patient stabilization, disease management education, risk factor modification, and promotion of self-care. We demonstrate a pioneering cost-avoidance model that could be applied to other chronic diseases.

University of North Carolina Health Care

University of North Carolina Health Care

Left to right: Leah Hatfield, Phil Mendys, Kevin Biese, Anil Gehi, Zack Deyo, Jennifer Walker, Heather Tuttle