The prevalence of atrial fibrillation (AFib) continues to rise, with the projected number of cases to exceed 12 million by the year 2030.1 Patients with atrial fibrillation often first seek medical attention through the emergency department (ED), where they present with symptoms or are referred by others.
Approximately 70% of patients who present to the ED with atrial fibrillation are ultimately admitted to the hospital as inpatients.2 The specific management that an individual patient with atrial fibrillation receives is often based on the personal preferences of the ED physician or the on-call cardiologist, which leads to significant variation in care, costs, and outcomes.
Approximately 10 years ago, the physicians at Spectrum Health noticed that an increasing number of patients being admitted for atrial fibrillation were clinically stable and probably did not require in-hospital care. Many of these patients would convert spontaneously to sinus rhythm and spend unnecessary hours (or even days) in the hospital awaiting various tests. In order to resolve this problem, a team of electrophysiology and emergency department physicians met and developed the “Spectrum Health AFib Protocol” for patients presenting to the ED with atrial fibrillation. The goal was to provide guideline-driven treatment for the acute stabilization of atrial fibrillation using both the ED and a telemetry observation unit, and to only admit patients whose condition warranted in-hospital care. Two algorithms were created: one for patients with acute onset of symptoms <48 hours in duration, and one for patients with unclear duration of atrial fibrillation or symptoms present >48 hours (Figures 1 and 2).
The other essential component of this pathway was to create an outpatient AFib Clinic, where patients would have timely follow-up after being discharged from the ED. The ED staff schedules an AFib Clinic visit at time of discharge from the ED, and that visit occurs within 72 business hours. The Spectrum Health AFib Clinic is comprised of physician assistants (PA) and nurse practitioners (NP) that specialize in cardiac electrophysiology, along with a dedicated registered nurse (RN) whose main emphasis is providing education about atrial fibrillation. The focus of this hour-long comprehensive visit includes an in-depth discussion of the various treatment strategies with an emphasis on symptom control, stroke reduction, and assessment of risk factors. Basic cardiac tests, including an ECG, monitor, and echocardiogram are ordered. A sleep apnea screening questionnaire is administered, and a referral to sleep medicine is made if appropriate. Other lifestyle risk factors for atrial fibrillation, including obesity and alcohol use, are addressed as well. Patients are then given a follow-up appointment in the next several weeks with either an electrophysiologist or cardiologist, where the results of the initial workup are reviewed and long-term AFib strategies are discussed in greater detail. Some patients may need only conservative treatment with lifestyle modifications, while other patients may benefit from more advanced interventional procedures, including ablation or left atrial appendage occlusion. (Figure 3)
The creation of our outpatient AFib Clinic was initially met with some criticism and skepticism. A large percentage of the patients referred from the ED to the AFib Clinic were new patients to our practice, and a long-standing group policy stated that all new patients must have an initial consultation with a physician. In order to provide early access to care, our AFib Clinic structure relies primarily on PAs and NPs for these initial clinics visits; patients typically may not meet a cardiac physician for several weeks after the initial visit. To address the concerns of some of our partners and referring doctors, we conducted a large survey of both patients seen in the AFib Clinic as well as their primary care physicians to obtain feedback on our new AFib Clinic structure and the care they received. The overwhelming sentiment was quite favorable, and the early access (2-3 days) to standardized protocol-based care was more important than meeting a physician during the initial AFib visit. In addition, we conducted a single-center study at Spectrum Health (EDIT AF) to assess the safety of this care pathway and protocol. The study concluded that usage of this ED-initiated AFib clinical pathway with early follow-up in a protocol-driven AFib clinic was associated with low readmission rates, no thromboembolic complications at 90 days, improved quality of life, and high patient satisfaction.3
Use of these interdisciplinary standardized care pathways in the ED and AFib Clinic reduces the need for in-hospital care, decreases the cost of care, and assures that patients all receive the same evidence-based approach, thus improving overall outcomes. Our ED AFib Pathway has resulted in a marked decline in hospital admissions for AFib since we implemented the pathway in 2010. At Spectrum Health, 20-25% of patients presenting to the ED with atrial fibrillation are now admitted, compared to almost 50% in 2008. (Figure 4)
In addition to patients coming through the ED pathway, there are several other referral sources to our AFib Clinic. Patients who present to primary care offices in new or poorly controlled atrial fibrillation are often referred directly to our clinic today, versus historically, when they were often sent to the ED for initial management. Another growing source of referrals to the AFib Clinic is our implantable cardiac device clinic. Patients with newly diagnosed atrial fibrillation discovered via remote monitor checks of pacemakers, defibrillators, or loop recorders are referred directly to the AFib Clinic via a protocol we created. The patient’s primary cardiologist or electrophysiologist is involved with the care plan via electronic health record communication, but the patient is seen initially in the AFib Clinic to start the education and treatment process.
Another recent revision to our AFib Clinic model was to include a telehealth option for patients in regional Spectrum Health locations that are not able or prefer not to travel to our main office in Grand Rapids, Michigan. This project began in Spring 2018, and we have already seen over 50 patients who live greater than 100 miles away from Grand Rapids via our the telehealth AFib Clinic this year. Not having to travel great distances to receive specialized consultative care has obvious benefits to both patients and the health care system.
Our comprehensive approach to the management of atrial fibrillation includes several other specialties in addition to the ED. Structural heart physicians, cardiac surgeons, sleep medicine specialists, neurologists, bariatric surgeons, preventative cardiologists, and heart failure physicians are all partners in the Spectrum Health AFib Program (Figure 5). Partnership with these specialists allows for comprehensive care and access to the most advanced contemporary procedures for the treatment of atrial fibrillation. We meet regularly with the various specialists in the AFib Program for ongoing collaboration and program growth. For example, we recently developed a monthly “Heart Brain Meeting” with our stroke neurologists, in which we review cases and establish pathways for patients with cryptogenic strokes, PFOs, or atrial fibrillation who may benefit from left atrial appendage occlusion or PFO closure. Similarly, we have quarterly meetings with our cardiac surgeons to review and revise our newly developed hybrid Convergent ablation program. Working together and not in “silos” with the various specialties is critical for a successful comprehensive AFib program.
Having the Spectrum Health system support and invest in our atrial fibrillation program is another key component to our success and ability to grow. In 2017, we created the position of an Atrial Fibrillation Coordinator. This position oversees quality, program growth, and development through networking and education, both internally and externally. The other primary responsibility of this position is to navigate patients through the complex, multi-step process involved in the advanced interventional procedures including catheter ablations, left atrial appendage occlusion, and hybrid surgical ablations. As our program continues to expand, the need for more operational support will likely increase as well. We are fortunate to have the commitment of our service line leaders to the success of our AFib Program.
As the AFib population grows, programs will see more and more patients across various care settings. A successful comprehensive AFib program requires pathways that identify and refer patients to the appropriate care setting. Operational and program efficiencies will become increasingly more important to allow for timely patient access and appropriate patient care. A multidisciplinary structure, standardized protocols, appropriate utilization of PAs and NPs, and institutional support are key factors for a successful atrial fibrillation program.
Disclosures: The authors have no conflicts of interest to report regarding the content herein. Outside the submitted work, Dr. Gauri reports he receives honoraria as a member of the Speakers' Bureau for Janssen Pharmaceuticals.
- Colilla S, Crow A, Petkun W, et al. Estimates of Current and Future Incidence and Prevalence of Atrial Fibrillation in the U.S. Adult Population. Am J Cardiol. 2013;112(8):1142-1147.
- Rozen G, Hosseini SM, Kaadan MI, et al. Emergency Department Visits for Atrial Fibrillation in the United States: Trends in Admission Rates and Economic Burden From 2007 to 2014. J Am Heart Assoc. 2018;7:e0009024.
- Elmouchi DA, VanOosterhout S, Muthusamy P, et al. Impact of an emergency department-initiated clinical protocol for the evaluation and treatment of atrial fibrillation. Crit Pathw Cardiol. 2014;13:43-48