Department of Family Medicine, Queen's University, Kingston.
Department of Medicine, McMaster University, ON.
Eur J Emerg Med. 2023 Oct 1;30(5):365-370. doi: 10.1097/MEJ.0000000000001072. Epub 2023 Jun 13.
The Canadian Association of Emergency Physicians atrial fibrillation (AF) checklist advises that emergency physicians initiate anticoagulation therapy for patients with AF or flutter who are CHADS65 positive.
The aim was to compare anticoagulation initiation rates between patients treated with and without an anticoagulation assessment pathway (the SAFE pathway).
This was a retrospective cohort study.
All emergency department patients were discharged home with a diagnosis of AF between June 2018 and May 2020 at two Canadian emergency departments.
The SAFE pathway is a hard copy form which allows emergency physicians to document contraindications to anticoagulation, the positive components of the CHADS65 score, and details how to prescribe anticoagulation.
Trained researchers abstracted data on the use of the SAFE pathway by the presence or absence of the completed, scanned pathway in the electronic medical chart. The exposure of interest was use of this pathway. Patients were followed forward in time for 90 days by electronic medical record review to document stroke, transient ischemic attack, arterial embolism and major bleeding events. All events were independently adjudicated. Adjusted odds ratios were calculated to compare outcomes between those managed with and without the SAFE pathway.
In total, 766 patients were included, of whom 264 were already taking anticoagulation, 166 were CHADS65 negative and 65 had a contraindication to anticoagulation, leaving 271 patients eligible for anticoagulation prescription. Among the 271 eligible patients, 137/166 managed with the SAFE pathway were initiated on anticoagulation and 24/105 managed without the SAFE pathway started anticoagulation (adjusted odds ratio 25.9; 13.1-51.2). There was no statistically significant difference in the 90-day rate of stroke or bleeding.
Use of the SAFE pathway was associated with a higher rate of anticoagulation prescription.
加拿大急诊医师协会心房颤动（AF）检查表建议，对于 CHADS65 评分阳性的 AF 或房扑患者，急诊医师应启动抗凝治疗。
本研究旨在比较使用抗凝评估路径（SAFE 路径）与未使用该路径的患者之间抗凝启动率的差异。
这是一项回顾性队列研究。
2018 年 6 月至 2020 年 5 月，加拿大两家急诊科所有以 AF 诊断出院的急诊患者。
SAFE 路径是一种纸质表单，允许急诊医师记录抗凝的禁忌证、CHADS65 评分的阳性成分以及如何开具抗凝药物的详细信息。
研究人员通过电子病历中是否存在完整的、扫描后的路径来提取使用 SAFE 路径的数据。感兴趣的暴露因素是使用该路径。通过电子病历记录，前瞻性随访 90 天，以记录卒中、短暂性脑缺血发作、动脉栓塞和大出血事件。所有事件均由独立的裁判裁定。计算调整后的优势比以比较使用和不使用 SAFE 路径的患者之间的结局。
共纳入 766 例患者，其中 264 例正在服用抗凝药物，166 例 CHADS65 评分阴性，65 例有抗凝禁忌证，271 例有抗凝药物处方适应证。在 271 例符合条件的患者中，使用 SAFE 路径管理的 137/166 例患者开始接受抗凝治疗，而未使用 SAFE 路径管理的 24/105 例患者开始接受抗凝治疗（调整后的优势比 25.9；13.1-51.2）。90 天内卒中或出血的发生率无统计学差异。
使用 SAFE 路径与更高的抗凝处方率相关。
