Managing Atrial Fibrillation in the Emergency Department

In this episode of The EP Edit podcast, we’re talking with Dr. DaMarcus Baymon and Dr. Christopher Baugh about their strategies for achieving best outcomes for patients with atrial fibrillation (AF or AFib) in the emergency department (ED). Dr. Baymon and Dr. Baugh are from the emergency medicine department at Brigham & Women's Hospital.

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Transcripts:

Thank you both for speaking with me today! Can you tell me a little about your role in the emergency department?

DB: I’m DaMarcus Baymon. I am an EM resident within the emergency department in my third year currently. We operate mostly in the clinical aspects and see patients and help get them to the proper places they need to be in the hospital.

CB: I’m Chris Baugh, I’m an emergency physician at Brigham and Women’s Hospital. My administrative title is Vice Chair of Clinical Affairs, and I work at the Brigham, which is a Boston academic urban teaching hospital that sees about 62,000 annual adult ED patients per year. I have the opportunity to work with emergency medicine residents like Dr. Baymon as part of my clinical role, and very much enjoy that opportunity.

What approximately is the incidence of atrial fibrillation seen in your emergency department? Would you say that the number of atrial fibrillation visits in the emergency department in the U.S. is on the rise?

CB: We have large databases that show that the number of visits primarily for atrial fibrillation or atrial flutter — we usually kind of bucket those two together — has been rising significantly in recent years. They would suggest that we’re talking about a half a million visits per year for these conditions. That has been rising significantly — if you look at say, gaps from the mid-2000s to mid-2000 teens, we’re talking about maybe a 25% increase in that period of time, which isn’t totally surprising given the high correlation of this arrhythmia to age and the aging demographics of the population in the United States.

What are some of the main challenges in treating atrial fibrillation in the emergency department?

DB: I think some of the main challenges involved are the lack of an established pathway in terms of how to properly treat these patients as well as proper outpatient coordination so we can avoid hospitalizations. I think we also need resources in the emergency department to help cardiovert these patients, because they need to be anticoagulated properly and going through the protocols to make sure that they can get their anticoagulation medication. Those are some of the main challenges of treating AF in the ED — making sure that once we treat them and they’re properly on their way to either being hospitalized or hopefully discharged from the emergency department, that we can discharge them and they have the proper care they need to ensure that they manage their AF in their outpatient care.

CB: That’s a really good point about follow-up care. Not all patients who are in the emergency department can get into a clinic in a reasonable timeframe after an ED visit. For someone who is going to be cardioverted for atrial fibrillation in the ED and then sent home, having access to a cardiologist within a few days of that ED visit is a really important part of the pathway to safely care for these patients. If that resource is not available, then the emergency physician may not have the confidence that a cardioversion and discharge plan is going to be safest for the patient, and they might default to hospitalizing that patient instead and lose that opportunity to keep the patient out of the hospital.

You outline a sample outpatient pathway for atrial fibrillation in your recent EP Lab Digest article. Can you describe more about the use of a multidisciplinary treatment pathway for atrial fibrillation?

DB: Yes, in terms of atrial fibrillation in a multidisciplinary pathway, I think we have a lot of different providers within the hospital. We have nurse practitioners, PAs, ED physicians, cardiologists, and EPs. In those pathways, we have to take each patient’s clinical case and use it, as each patient is unique. So in terms of that, we have to use different criteria such as their rate, their comorbidities, and how long they have been in AF as markers to properly treat the patient. Once we use those things, going back to outpatient care with a cardiologist is I think the biggest part in making sure that we take care of these patients properly. Then the question is if we’re going to cardiovert or not, and what that means to the patient’s long-term outcomes.

Does an AF care pathway strategy help reduce costs or have an impact on factors such as hospital admission rates or repeat ED visits?

CB: I think it’s important to realize that we’re talking a lot about cardioversion. It’s an important part of what we talked about in our piece, but not all patients who come to the ED with a primary problem with atrial fibrillation are going to be eligible for cardioversion. It’s going to be significant, but it’s actually not the majority of patients. Perhaps they’ll have an active comorbidity like acute decompensated heart failure and it really does merit hospitalization, or they’ll have an unknown or long duration of atrial fibrillation that would make cardioversion unsafe from a thromboembolic risk perspective. So that’s a big piece of the pathway identifying eligible patients for cardioversion. Once you have identified the patients who are eligible and then actually cardiovert them and send them home, then that’s where you’re really bending the curve around the hospitalization or admission trends. You can decrease the admission rate by about 20% to 40%, as some previous studies have suggested, and you probably would expect that the lack of hospitalization really drives down cost production, because time in the hospital is quite costly in the United States. So being able to get someone directly home from the emergency department versus what would typically be a two- to three-day hospitalization really does end up reducing costs.

What is the role of the emergency department in the management of atrial fibrillation, and why is the emergency physician integral in the care of atrial fibrillation?

DB: I think one of the major roles of the emergency department, especially as a resident, is making sure the patients have their rates controlled, making sure they’re properly anticoagulated if they need to be based on their comorbidities, and also, in terms of the management of AF, if they need to be hospitalized or not. So that is the first role that we have as emergency physicians, because we need to help decrease hospitalizations, reduce costs, and hopefully provide fewer thromboembolic events in patients. Also, I think closing the gap between the usual care for patients with AF and best practices involves the ED in terms of collaborating via a multidisciplinary approach in the management of AF. Providing good emergency department care and a good plan for patients depending on where they go — whether they go home or whether they go into the hospital — and having the patients understand that plan and then implementing that plan is the emergency department’s key role, because a lot of patients will present with new-onset atrial fibrillation or AF exacerbations, and determining the difference between those two and how to care for the patient is key.

Thank you again for your time today. Is there anything else that you’d like to add?

CB: I would just add that the care of atrial fibrillation patients in the emergency department is really a tremendous opportunity to develop deep collaborations between staff in the emergency department and other specialty groups, in particular cardiology. Those extend into other populations of patients, such as patients presenting with chest pain or congestive heart failure. You can then create this virtuous cycle of collaboration where you’re expediting care for patients who most need it, and you’re avoiding hospitalizations when alternative pathways aren’t available. That has certainly been my experience at my own hospital. I would encourage champions and leaders from the emergency department and other specialty groups such as cardiology to really start having those conversations to build these pathways.

DB: I agree as well. Our cardiologists at the Brigham are very happy to come by our emergency department observation unit and take care of those patients properly, and I think that is huge for the care of these patients.