LO40: Safe anticoagulation initiation for atrial fibrillation in the emergency department (the SAFE pathway)

Abstract

Background: Atrial fibrillation (AF) is a risk for stroke. The Canadian Cardiovascular Society advises patients who are CHADS65 positive should be started on oral anticoagulation (OAC). Our local emergency department (ED) review showed that only 16% of CHADS65 positive patients were started on OAC and that 2% of our patients were diagnosed with stroke within 90 days. We implemented a new pathway for initiation of OAC in the ED (the SAFE pathway). Aim Statement: We report the effectiveness and safety of the SAFE pathway for initiation of OAC in patients treated for AF in the ED. Measures & Design: A multidisciplinary group of physicians and pharmacist developed the SAFE pathway for patients who are discharged home from the ED with a diagnosis of AF. Step 1: contraindications to OAC, Step 2: CHADS65 score, Step 3: OAC dosing if indicated. The pathway triggers referral to AF clinic, family physician letter and follow up call from the ED pharmacist. Patients are followed for 90 days by a structured medical record review and a structured telephone interview. We record persistence with OAC, stroke, TIA, systemic arterial embolism and major bleeding (ISTH criteria). Patient outcomes are fed back to the treating ED physician. Evaluation/ Results: The SAFE pathway was introduced in two EDs in June 2018. In total, 177 patients have had the pathway applied. The median age was 70 (interquartile range (IQR) 61-78), 48% male, median CHADS2 score 2 (IQR 0-2). 19/177 patients (11%) had a contraindication to initiating OAC. 122 patients (69%) had no contraindication to OAC and were CHADS65 positive. Of these 122 patients, 109 were given a prescription for OAC (96 the correct dose, 9 too high a dose and 4 too low a dose). 6 patients declined OAC and the physician did not want to start OAC for 7 patients. 73/122 were contacted by phone at 90 days, 15 could not be reached and 34 have not completed 90 days of follow up since their ED visit. Of the 73 who were reached by phone after 90 days, 65 were still taking an anticoagulant. To date, 1 patient who declined OAC (CHADS2 score of 2) had a stroke within 90 days and one patient prescribed OAC had a gastrointestinal bleed. Discussion/Impact: The SAFE pathway appears safe and effective although we continue to evaluate and improve the process.

Integrated Care for Atrial Fibrillation Management: The Role of the Pharmacist

“…Arguably, the interventions most suitably aligned to a pharmacist"s skillset are those that focus on medication initiation, optimization and education. Pharmacist-led anticoagulant management services comprised of education, 18,20,27,28,33,36,37,44 adverse event monitoring 19,27,29,33,35,37,39,41,44 and dose-adjustment 18,20,37,44 were the most common interventions tested, as well as pharmacist identification of people with an atrial fibrillation diagnosis recorded with no evidence of anticoagulant prescription. 22,25,38,43,45 Overall, pharmacist interventions increased OAC prescription rates in eligible patients, and improved the appropriateness of prescribing.…”

“…32,38 Studies included patients on warfarin (n=9), 18-20, 23, 30, 36, 37, 39, 44 non-vitamin K antagonist oral anticoagulants (NOACs) (n=8) 17,27,[31][32][33][34][35]41 or both (n=1). 46 Nine studies referred broadly to anticoagulants, 22,24,25,28,29,38,40,43,45 and three evaluated antithrombotics. 21,26,42 Seven studies reported the quality of warfarin therapy, measured by time in therapeutic range (TTR), 18,20,30,36,37,39,44 seven reported on health outcomes (thromboembolism, bleeding, mortality), 19,27,29,33,35,39,44 15 reported on oral anticoagulant (OAC) prescribing, 21-26, 31, 34, 38, 40, 42, 43, 45, 46 28 one on patient knowledge 32 , one on patient cognition, 17 two on patient satisfaction 17,28 , and three on medication adherence.…”

“…46 Nine studies referred broadly to anticoagulants, 22,24,25,28,29,38,40,43,45 and three evaluated antithrombotics. 21,26,42 Seven studies reported the quality of warfarin therapy, measured by time in therapeutic range (TTR), 18,20,30,36,37,39,44 seven reported on health outcomes (thromboembolism, bleeding, mortality), 19,27,29,33,35,39,44 15 reported on oral anticoagulant (OAC) prescribing, 21-26, 31, 34, 38, 40, 42, 43, 45, 46 28 one on patient knowledge 32 , one on patient cognition, 17 two on patient satisfaction 17,28 , and three on medication adherence. 32,33,41 Five of these studies reported on two outcomes, including TTR and health outcomes, 39,44 medication adherence and health outcomes, 33 patient satisfaction and OAC prescribing, 28 patient satisfaction and cognition, 17 and patient knowledge and medication adherence.…”

“…Seven studies reported on health outcomes 19,27,29,33,35,39,44 (Table 2). Only one study that used a before-and-after design was powered to performed adjusted analyses, 39 and found a pharmacist-led anticoagulant management services focused on TTR improvement was associated with lower odds of a composite endpoint of clinically-relevant bleeding, thromboembolism and all-cause mortality (adjusted odds ratio [OR] 0.69, 95% CI 0.54-0.87).…”