Impact of an Emergency Department Observation Unit Management Algorithm for Atrial Fibrillation

Abstract

Background: Atrial fibrillation (AF) is a common, growing, and costly medical condition. We aimed to evaluate the impact of a management algorithm for symptomatic AF that used an emergency department observation unit on hospital admission rates and patient outcomes.

Methods and results: This retrospective cohort study compared 563 patients who presented consecutively in the year after implementation of the algorithm, from July 2013 through June 2014 (intervention group), with 627 patients in a historical cohort (preintervention group) who presented consecutively from July 2011 through June 2012. All patients who consented to have their records used for chart review were included if they had a primary final emergency department diagnosis of AF. We observed no significant differences in age, sex, vital signs, body mass index, or CHADS2 (congestive heart failure, hypertension, age, diabetes mellitus, and prior stroke or transient ischemic attack) score between the preintervention and intervention groups. The rate of inpatient admission was significantly lower in the intervention group (from 45% to 36%; P<0.001). The groups were not significantly different with regard to rates of return emergency department visits (19% versus 17%; P=0.48), hospitalization (18% versus 16%; P=0.22), or adverse events (2% versus 2%; P=0.95) within 30 days. Emergency department observation unit admissions were 40% (P<0.001) less costly than inpatient hospital admissions of ≤1 day's duration.

Conclusions: Implementation of an emergency department observation unit AF algorithm was associated with significantly decreased hospital admissions without increasing the rates of return emergency department visits, hospitalization, or adverse events within 30 days.

Keywords: anticoagulants; arrhythmia; fibrillation.

Figure 1

Management algorithm for atrial fibrillation. CHADS ₂ indicates congestive heart failure, hypertension, age, diabetes mellitus, and prior stroke or transient ischemic attack; ECV, electrical cardioversion; ED, emergency department; EDOU, emergency department observation unit; NPO, nil per os (nothing by mouth); TEE, transesophageal echocardiography.

Figure 2

Relative total costs, stratified by category, for patients admitted to the EDOU vs inpatient service. Circle sizes are proportionate to the respective costs of care (40% lower for patients managed in the EDOU). “Inpatient” represents patients hospitalized for ≤1 day. Echo indicates echocardiography; ECV, electrical cardioversion; ED, emergency department; EDOU, emergency department observation unit; professional, cost charged by physicians or advanced practice providers.