Comprehensive atrial fibrillation package of care to minimise unnecessary hospital admission and improve patient outcome: a quality improvement project
Authors: Ohn M , Abdul F , Bhardwaj S 
Published: May 2024

Abstract

Funding Acknowledgements
None.

Introduction
Recent studies have highlighted an increasing rate of hospitalisation among atrial fibrillation (AF) patients, despite a relatively low in-hospital mortality rate. This trend carries significant financial implications, with a twofold increase in AF-related expenditures, over 50% of which are associated with inpatient care.

Purpose
A Quality Improvement Project (QIP) was conducted to enhance AF care, reduce unnecessary admissions, and address the root causes driving increased hospitalisations.

Methods
The root cause analysis, illustrated in Figure 1, revealed four factors contributing to the increased hospital admission rate of newly diagnosed AF patients: systemic issues, the nature of the disease itself, patient and physician-related factors. The driver diagram (Figure 2) visually presented the primary and secondary drivers with corresponding interventions targeting potential areas for improvement. Plan, Do, Study, Act (PDSA) cycle was conducted using four-pronged approach: 1. Updating local guidelines and designing a stepwise algorithm to align with contemporary standards of care. 2. Establishing an ambulatory care/arrhythmia clinic referral pathway for follow-up of stable AF patients to ensure continuity of care, thus minimizing unnecessary admissions. 3. Implementing a safe discharge toolkit comprising patient education materials, a poster for stroke and bleeding risk assessment tools, and an anticoagulation checklist. 4. Incorporating AF management teaching sessions into the doctors’ induction curriculum to enhance their knowledge and confidence in managing newly diagnosed AF patients and ensuring safe discharges.

Results
Lack of an ambulatory care or arrhythmia clinic referral pathway, inadequate educational resources, insufficient clinician training were key factors contributing to unwarranted hospitalization of newly diagnosed AF patients. The comprehensive guideline revision process, requiring substantial resources and the support of stakeholders and a multidisciplinary team comprising cardiologists and emergency and acute medical physicians, facilitated the successful implementation of the new AF referral pathway. This QIP resulted in a 16% reduction in avoidable admissions, 24% increase in clinician confidence, and 18% improvement in adherence to stroke and bleeding risk assessment protocols, in addition to reducing the hospital stay duration.

Conclusions
The collaboration among diverse medical disciplines, evidence-based guideline revision, and the implementation of a streamlined AF referral pathway demonstrated the potential to reduce healthcare resource utilization and financial burdens. This approach aligns with national standards, enhances healthcare providers' knowledge and confidence, ensuring standardised clinical practices. It underscores its potential for implementation of similar pathways to improve patient care. Continuous evaluation to evolving guidelines are recommended for sustainability.Figure 1.Ishikawa fishbone diagramFigure 2.Driver diagram for AF care