Atrial Fibrillation (AFIB) is one of the leading cardiac causes of visits to the Emergency Departments (ED) in Ontario. However a subset of these ED visits for AFIB could be managed just as safely in the community by care providers with training and support. In addition, between 10 to 40% of these patients will be admitted to hospital, and a number of these admissions are potentially avoidable. Furthermore, AFIB that is not related to a reversible cause significantly increases the risk of stroke in these patients. AFIB-related strokes are fatal in up to 20% of patients and 60% are left with a permanent disability. Many patients with AFIB are not receiving preventative treatments. The fragmentation of care of this chronic condition is a driver for avoidable health utilization and costs.
To address this, the Atrial Fibrillation Quality Care Program (AFQCP) was created to provide a multipronged intervention targeting ED AFIB patients and facilitating both their ED management as well as streamlining their transition back to community care with support for both the patients and their primary care provide.
Innovative and creative aspects of the AFQCP include:
1. Utilization of a Nurse Practitioner and Pharmacist-led model with physician support
2. Tailored patient education on AFIB, including clear advice on how to self-manage
3. Access to specialty care through telemedicine
4. Access to the AFQCP team through a 1-855 hotline
5. Patient-friendly, standardized, individualized care plans, provided at the end of each clinic visit
6. Individualized guideline-based, standardized family practitioner care plans formatted to include the important information but structured to address the key components of AFIB care (stroke prevention and quality of life) and to also clearly communicate what the next steps for the patient are and who is taking responsibility
7. A specialized, disease-specific clinic with the goal of transitioning the patient back to Primary Care with a shared care model
The Acute Management includes: ED clinicians’ access to management pathway and guideline-based acute AFIB management order sets to ensure consistent approach to care. Patients safe to be discharged home are provided with AFIB education package and AFQCP referral. Patients leave with an appointment and information about caregivers and what to expect at the initial visit.
The Transition Back to Primary Care includes: The AFQCP is a nurse practitioner and pharmacist-led, multidisciplinary shared care model and features: guideline-based standardized assessments, decision support tools, medication reconciliation at each visit, tailored education for patients, symptom control, self-management of future acute AFIB episodes, access to diagnostic testing, often right in the clinic environment, access to as-needed involvement of specialty care (such as electrophysiology consultation),standardized, guideline-based care plan for communication to the primary care provider and a hand-written customized care plan provided to the patient at the end of the visit, and access to a 1-855 hotline
Positive improvements in patient-reported quality of life, as assessed by the validated AFEQT questionnaire, have been found with improvements noted in all subscales; symptoms, activities of daily living, treatment concern, and treatment satisfaction. More than 3 months after the initial AFQCP visit, 85% of patients are maintaining guideline-based stroke prevention treatment, and another 8% of patient have clinically-valid reasons for not maintaining this. With respect to the patient-support hotline, in a 16 month period, the team received a total of 34 calls from 14 patients (and 4 calls from 4 healthcare providers). In nine of the patient calls, they indicated that they would have gone straight to the ED without this service, and in all cases, the receiver also indicated that an ED visit was prevented. Notably, in four cases where the caller indicated that they would not have gone directly to the ED, the receiver actually referred one patient to the ED given the clinical scenario and brought 3 patients back to the clinic for an urgent review. Patient Satisfaction: All patients interviewed describe the AFQCP as a positive experience. Patients appreciate the time and attention they receive at the clinic, like having the opportunity to gain confidence and knowledge about their medical condition and the time to ask questions in a supportive environment, and like having access to a collaborative, multidisciplinary team.
This leading practice involves other hospitals as collaborators:
- Women’s College Hospital, St. Michael’s Hospital and Mount Sinai Emergency Department.
Contact Title: Senior Analyst, Clinical Risk and Patient Safety
Contact Email: Ruxandra.Nedu@uhn.ca