Quality of emergency room care for atrial fibrillation

Figures & data

Table I.  Patient characteristics.

	Male, n = 110 n (%)	Female, n = 69 n (%)	p
Age, years, mean (range)	58.7±12.9 (21–84)	68.9±10.9 (35–86)	<0.001
AF duration < 2 days	83 (75.5)	53 (76.8)	0.860
Previous AF	87 (79.1)	51 (73.9)	0.467
Previous cardioversion	75 (68.2)	41 (59.4)	0.262
Cardiological work-up including echocardiography	45 (40.9)	16 (23.2)	0.016
Hypertension	52 (47.3)	37 (53.6)	0.445
Ischaemic heart disease	26 (23.6)	11 (15.9)	0.258
Valvular disease	10 (9.1)	16 (23.2)	0.015
Thyroid disease	1 (0.9)	1 (1.4)	1.000
Prior stroke	5 (4.5)	7 (10.1)	0.218
Diabetes	9 (8.2)	5 (7.2)	1.000
Alcohol abuse	10 (9.1)	4 (5.8)	0.571
Retired	55 (50.0)	53 (76.8)	0.001
Living alone	20 (18.2)	32 (46.4)	<0.001

Figure 1.  Ventricular response rate at the time of admission to ER and use of rate-slowing medication given in the ER (digitalis or/and beta-adrenergic blocking agent).

Table II.  Preceding cardiovascular medication before and the modifications in these drug groups during the emergency room visit (including significant dose adjustments,% of all patients).

	Before, n (%)	Started or modified during the ER visit, n (%)
Warfarin	27 (15.1)	32 (17.9)
Aspirin	61 (34.1)	1 (0.6)
Other	5 ( 2.8)	1 (0.6)
β-blocker	100 (55.9)	28 (15.6)
Digitalis	14 (7.8)	9 (5.0)
ATII/ACE	60 (33.5)	3 (1.7)
Flecainide	23 (12.8)	3 (1.7)
Sotalol	17 (9.5)	4 (2.2)
Disopyramide	6 (3.4)	0 (0.0)
Propafenone	4 (2.2)	2 (1.1)
Amiodarone	3 (1.7)	3 (1.7)
Quinidine	1 (0.6)	1 (0.6)

β-blocker = a beta-adrenergic blocking agent.

ATII/ACE = an angiotensin II receptor antagonist or an angiotensin-converting enzyme inhibitors.

Figure 2.  Treatment procedures for AF and the outcomes in the emergency room.

Figure 3.  Assessment of the quality of AF care in the ER. For detailed criteria, see Appendix. a) classification of AF b) recording medical history c) clinical assessment d) therapeutic decisions e) plans for follow-up

Table III.  Quality of care with (n = 109) or without (n = 70) cardioversion

	Inadequate n (%)	Fair n (%)	Good n (%)	p
Classification of AF
CV	0 (0.0)	12 (11.0)	97 (89.0)	0.167
No CV	2 (2.9)	1 (1.4)	67 (95.7)
Recording medical history
CV	4 (3.7)	20 (18.3)	85 (78.0)	0.672
No CV	0 (0.0)	14 (20.0)	56 (80.0)
Clinical assessment
CV	1 (0.9)	16 (14.7)	92 (84.4)	0.837
No CV	0 (0.0)	12 (17.1)	58 (82.9)
Therapeutic decisions
CV	3 (2.8)	13 (11.9)	93 ( 85.3)	0.042
No CV	1 (0.9)	2 (2.9)	67 (95.7)
Plans for follow-up
CV	3 (2.8)	21 (19.3)	84 (77.1)	0.468
No CV	3 (4.2)	9 (12.9)	58 ( 82.9)

Table

Good:	guideline requirements fulfilled
Fair:	minor deficiency or non-justified deviation
Inadequate:	posing a potential disadvantage or threat to the patient
Typical examples: Classification of AF (paroxysmal, persistent, permanent)
Inadequate:	AF not listed as diagnosis
	Wrong diagnosis
Fair:	AF listed as diagnosis but missing or wrong classification
Good	Appropriate classification
Recording medical history
Inadequate:	Background morbidity, medication, possible previous AF or duration of current AF not listed
Fair:	One of the above missing
Good:	Sufficient information available
Clinical assessment
Inadequate:	Cardiovascular assessment (vital functions, decompensation, ischemia) missing or erroneous
Fair:	High initial blood pressure or ventricular response rate not appropriately recognized
Good:	Careful clinical examination with appropriate interpretation
Therapeutic decisions
Inadequate:	Inappropriate polypharmacy, anticoagulation against guidelines, discharge of unstable patient
Fair:	Minor deviation from guidelines in a typical case of AF
	Insufficient care of myocardial ischemia or heart failure
Good:	Treatment in line with guidelines
Plans for follow-up
Inadequate:	Need of anticoagulation not recognized, insufficient follow-up of new medication, responsibility for further treatment poorly defined
Fair:	Deviation from guidelines without explicit reason, e.g. cardiac work-up not scheduled, need to modify drug dosing not mentioned
Good:	Appropriate plan distinctly communicated