DC cardioversion of atrial fibrillation and atrial flutter in the emergency department: improving specialist protocols for the generalist

Abstract

BackgroundDirect current cardioversion (DCCV) is a safe and effective treatment for recent-onset atrial fibrillation (AF) or flutter and when performed in the emergency department (ED), it can provide an excellent treatment option for patients as well as reducing unnecessary hospital admissions and healthcare costs. However, appropriate periprocedural anticoagulation is absolutely essential to reduce the risk of adverse outcomes, chiefly thromboembolic stroke. Our intention was for 100% of patients undergoing DCCV in the ED to receive appropriate periprocedural anticoagulation.MethodWe aimed to assess local practice with regards to periprocedural anticoagulation with a 1-year retrospective audit. We then undertook to deliver a multimodality educational programme in addition to producing new local protocols. Stakeholders were engaged within the cardiology, emergency medicine and governance departments as well as trust quality improvement team. This was undertaken across three PDSA cycles with prospective data collection on a rolling monthly basis with the use of real-time run charts, fed back to the ED. Teaching was delivered on a small group, electronic as well as departmental level, and a new protocol was created and delivered to guide clinicians in the management of patients with AF or flutter.ResultsWhile initial rates of periprocedural anticoagulation were suboptimal (with only 72% of eligible patients anticoagulated), following our programme of continuous monitoring and intervention, this steadily rose over the project timeline, achieving a high of 91% at the point of last data collection.ConclusionWe should champion the high number of these procedures carried out in the ED setting, a pressured environment with multiple competing challenges. However, local protocols should reflect best-practice guidance regarding decision-making around selecting rate versus rhythm control strategies, appropriate use of medication and eligibility for anticoagulation as per individualised thrombotic risk. This will allow us to deliver effective interventions in a safe, patient-centred approach.