Stiell Ian G, Archambault Patrick M, Morris Judy, Mercier Eric, Eagles Debra, Perry Jeffrey J, Scheuermeyer Frank, Clark Greg, Gosselin Sophie, Vadeboncoeur Alain, Parkash Ratika, de Wit Kerstin, Patey Andrea M, Thiruganasambandamoorthy Venkatesh, Taljaard Monica
Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada.
Département de Médecine Familiale et de Médicine d'Urgence, Université Laval, Québec, Québec, Canada; Département d'Anesthésiologie et de Soins Intensifs, Université Laval, Québec, Québec, Canada.
Can J Cardiol. 2021 Oct;37(10):1569-1577. doi: 10.1016/j.cjca.2021.06.016. Epub 2021 Jul 1.
We sought to improve care of patients with acute atrial fibrillation (AF) and flutter (AFL) in the emergency department (ED) by implementing the Canadian Association of Emergency Physicians (CAEP) Acute AF/AFL Best Practices Checklist.
We conducted a stepped-wedge cluster randomised trial at 11 large community and academic hospital EDs in 5 Canadian provinces and enrolled consecutive AF/AFL patients. The study intervention was introduction of the CAEP Checklist with the use of a knowledge translation-implementation approach that included behaviour change techniques and organisation/system-level strategies. The primary outcome was length of stay in ED, and secondary outcomes were discharge home, use of rhythm control, adverse events, and 30-day status. Analysis used mixed-effects regression adjusting for covariates.
Patient visits in the control (n = 314) and intervention (n = 404) periods were similar with mean age 62.9 years, 54% male, 71% onset < 12 hours, and 86% AF, 14% AFL. We observed a reduction in length of stay of 20.9% (95% confidence interval [CI] 5.5%-33.8%; P = 0.01), an increase in use of rhythm control (adjusted odds ratio [OR] 4.5, 95% CI 1.8-11.6; P = 0.002), and a decrease in use of rate-control medications (OR 0.5, 95% CI 0.2-0.9; P = 0.02). There was no change in adverse events and no strokes or deaths by 30 days.
The RAFF-3 trial led to optimised care of AF/AFL patients with decreased ED lengths of stay, increased ED rhythm control by drug or electricity, and no increase in adverse events. Early cardioversion allows AF/AFL patients to quickly resume normal activities.
我们试图通过实施加拿大急诊医师协会（CAEP）急性房颤/房扑最佳实践清单来改善急诊科（ED）急性房颤（AF）和房扑（AFL）患者的护理。
我们在加拿大5个省份的11家大型社区和学术医院急诊科进行了一项阶梯式楔形整群随机试验，并纳入连续的房颤/房扑患者。研究干预措施是采用知识转化实施方法引入CAEP清单，该方法包括行为改变技术和组织/系统层面的策略。主要结局是急诊科留观时间，次要结局是出院回家、节律控制的使用情况、不良事件和30天状态。分析采用混合效应回归并对协变量进行调整。
对照组（n = 314）和干预组（n = 404）的患者就诊情况相似，平均年龄62.9岁，男性占54%，71%起病时间<12小时，86%为房颤，14%为房扑。我们观察到留观时间缩短了20.9%（95%置信区间[CI] 5.5% - 33.8%；P = 0.01），节律控制的使用增加（调整后的优势比[OR] 4.5，95% CI 1.8 - 11.6；P = 0.002），而控制心率药物的使用减少（OR 0.5，95% CI 0.2 - 0.9；P = 0.02）。不良事件无变化，3日天内无卒中或死亡病例。
RAFF - 3试验实现了对房颤/房扑患者的优化护理，缩短了急诊科留观时间，增加了药物或电复律在急诊科的节律控制应用，且不良事件未增加。早期复律可使房颤/房扑患者迅速恢复正常活动。
