Oxford University Hospitals NHS Trust
The vast majority of patients attending the Emergency department undergo an ECG as part of the initial investigations.
The recent new NICE guidelines on Atrial Fibrillation suggest that the baseline prevalence for Atrial Fibrillation is above 7% in the over 65 population and over 10% in the over 75. They suggest that targeted opportunistic screening may help identify these patients earlier (NICE CG180 recommendation 1.1.2)
Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?
Aims and objectives
The main aims of this study were to identify whether the Emergency Department diagnoses a significant proportion of patients with new Atrial Fibrillation. The secondary aims were to characterise these patients and potentially help modify local practice to help reduce the incidence of avoidable strokes.
Reasons for implementing your project
This project initially started due to observations of emergency physicians who had noted several recent new diagnoses of Atrial Fibrillation in the department. In addition, the new NICE guidelines were published and therefore this study aimed to compare practice and figures with those published by NICE. As recognised by the NICE guideline development committee, Atrial Fibrillation is difficult to detect early and opportunistic ECG's in the emergency department may identify these patients.
A pilot study was performed first, investigating adults who had attended the Royal Berkshire Hospital Emergency Department over a week and who had had an ECG on arrival.
How did you implement the project
The study was led by the SHO with some guidance from an Emergency Medicine consultant. This project retrospectively identified those patients with a new diagnosis of Atrial Fibrillation made in the Emergency department based on their admission ECG. In addition demographics, past medical history and a CHADs2Vasc score was calculated. The project looked at all admissions over 30 days in the emergency department.
Patients who were eligible were over 16 (on admission) and had a documented ECG performed. The electronic notes were consulted to look for the admission ECG performed, initial clerking and demographics. Patients were excluded if no copy of the initial ECG was available.
Overall, 3251 patients were screened, of which 584 had an ECG in the department on admission. Of these 93 were excluded (ECG unavailable) leaving a total of 491 patients who were eligible. Of these 16 had a new diagnosis of Atrial Fibrillation (3.2%) (95% CI 2 - 5%). The average age of these patients with new diagnoses was 78 compared to 62 years of the population who had an ECG. These patients also had a mean CHADs2Vasc score of 2.6, of which 11 required consideration for warfarin or similar. The prevalence of newly detected AF as a proportion of all patients attending the ED during the study period was 0.49% (95% CI 0.3 - 0.8%). However, the prevalence of newly detected AF in those documented to have an ECG was 2.7% (95% CI 1.96 - 4.4%).
The NICE guidance focuses on the management of Atrial fibrillation however, has less to say about the early detection of atrial fibrillation. Although early detection is usually considered the responsibility of the primary care physician, many patients do not regularly attend their GP or may only present to hospital when ill. Therefore, with thousands of ECGs being performed in Emergency Departments, there is a wealth of data being collected.
The results did confirm our suspicions that there was a significant number of patients who had a new diagnosis of Atrial Fibrillation made in the Emergency Department.
Key learning points
This project emphasises the need for further collaboration between Emergency Departments, Primary care facilities and Public Health. A significant number of new diagnoses of Atrial Fibrillation are made in the Emergency department.
Dr Jonathan Sunkersing and Dr Manish Thakker
CT1 Emergency Medicine & Consultant in Emergency Medicine
Oxford University Hospitals NHS Trust
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