Improving DC cardioversion of atrial fibrillation and atrial flutter in the Emergency Department

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Background & Problem

Atrial fibrillation and flutter are common cardiac arrhythmias, both of which account for significant healthcare expenditure in particular increased costs from hospital admission. Direct current (DC) cardioversion of these arrhythmias in the Emergency Department (ED) aims to restore a normal heart rhythm with an electric shock and often allows avoidance of admission. However, risk of forming blood clots which may lead to significant morbidity and mortality is highest around the time of this shock. This risk can be mitigated by following best-practise guidance and considering appropriate anticoagulation peri-procedure.

Aim

We aimed to ensure 100% of patients at both CGH and GRH Emergency Departments who received DCCV for atrial fibrillation or atrial flutter received appropriate periprocedural anticoagulation. We also reviewed other aspects of management including appropriate follow-up for these patients.

Method

We undertook an initial retrospective analysis of all patients cardioverted for atrial fibrillation or flutter in the ED over a 1 year period. We then prospectively recorded this data. At several stages we implemented interventions including group and individual-focused teaching interventions, widespread systems change with an updated Trust protocol, as well as awareness-raising strategies including email bulletins.

Results

Our initial retrospective analysis revealed a sub-optimal level of patient management with only 75% of cardioversion patients receiving appropriate peri-procedural anticoagulation. Over the study period, this rose steadily. Qualitative feedback was also received of a favourable nature, specifically regarding group teaching as well as the new protocol we introduced which doctors found clear and workable.

Implications

Encouraging change in practise is always challenging, but we adopted a multi-pronged approach. Of particular usefulness was the new protocol which was easily accessible and user-friendly, enabling doctors to easily follow evidence-based and a safe practise.
Group and individual teaching sessions have played an integral part in our attempts to implement change. Future opportunities to promote improvement include additional educational sessions with the ED staff through ‘’message of the week’’ and ‘’theme of the fortnight’’ where we will present our project in an interactive setting as well as involving the medical registrars who are often directly involved in the care of these patients within the ED.