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Atrial fibrillation in small-volume EDs
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Hi everyone!Some recently published data from Alberta (Hawkins, Ann Emerg Med 2021; disclosure: I am a co-author) indicate that the one-year mortality of emergency department patients with atrial fibrillation and flutter are similar no matter whether you the patient is treated in a high-volume or low-volume ED.
However, patients in low-volume EDs are more likely to be admitted, less likely to be cardioverted, and are more likely to have a 30-day revisit than those in moderate- or high-volume EDs. The reasons for these disparities in care and outcomes are unclear, but would be of great interest. For what it is worth, the data examined patients from 2009 to 2015--the CAEP AFF guidelines were published in 2018, and these may have assisted in standardizing care across EDs. (https://caep.ca/wp-content/uploads/2018/09/caep_acute_atrial_fibrillationflutter_best_practices_checklist_final.pdf)
Thoughts?
The Hawkins paper is at https://www.annemergmed.com/article/S0196-0644(21)00227-4/fulltext (paywalled of course).
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There are a few reasons why these differences exist. Few thoughts:
1. Rural hospitals often have more beds to admit to - a major influencer on admissions is a capacity to admit. Rather than thinking rural hospitals admit too often, it could be that high volume hospitals don't admit enough.
2. Often rural/remote patients are well, remote from even the hospital so follow up is more challenging. For example, in our catchment, we have a community of 400 on a nearby island with no overnight access to hospital. Patients with new fast AF from Sandspit will be admitted out of compassion and common sense.
3. Electrical CV is inherently more risky in lower volume EDs as many won't have anesthesia, IM or cardiology and comfort varies with sedation.
4. Revisit rates - rural EDs have much shorter wait times and often handle lesser acuities as a result, lowering barriers for many who may not wish to present to a busy ED and sit long periods in a WR.
Dr. Julian Marsden
September 21, 2021