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Canadian Journal of Cardiology

RAFF-3 Trial: A Stepped-Wedge Cluster Randomised Trial to Improve Care of Acute Atrial Fibrillation and Flutter in the Emergency Department

      ABSTRACT

      Background

      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.

      Methods

      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.

      Results

      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.

      Conclusions

      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.

      RÉSUMÉ

      Contexte

      En vue d'améliorer les soins prodigués aux patients admis au service des urgences (SU) à la suite d’épisodes de fibrillation ou de flutter auriculaires aigus, nous avons eu recours à la Liste de vérification des meilleurs [sic] pratiques en matière de fibrillation et flutter auriculaires aigus de l'Association canadienne des médecins d'urgence (ACMU).

      Méthodologie

      Nous avons mené un essai à répartition aléatoire par grappes et par étapes dans cinq provinces canadiennes chez des patients admis successivement au SU de 11 grands hôpitaux communautaires et universitaires à la suite d’épisodes de fibrillation ou de flutter auriculaires aigus. L'intervention à l’étude consistait à utiliser la Liste de vérification de l'ACMU dans le cadre d'une démarche de transfert et de mise en œuvre des connaissances faisant notamment appel à des techniques de modification des comportements et à des stratégies organisationnelles et systémiques. Le critère d’évaluation principal de l'essai était la durée du séjour au SU; le retour des patients à leur domicile après leur hospitalisation, le recours au contrôle du rythme, les événements indésirables et l’état de santé des patients après 30 jours en étaient les critères d’évaluation secondaires. L'analyse faisait appel à la régression à effets mixtes avec ajustement en fonction des covariables.

      Résultats

      Le nombre de consultations était similaire au cours des périodes témoin (n = 314) et d'intervention (n = 404), les patients étaient âgés en moyenne de 62,9 ans, 54 % étaient des hommes, 71 % ont consulté moins de 12 heures après l'apparition des symptômes d'appel, 86 % présentaient une fibrillation auriculaire et 14 %, un flutter auriculaire. Nous avons observé une diminution de la durée du séjour de 20,9 % (intervalle de confiance [IC] à 95 % : 5,5 %-33,8 %; p = 0,01), une augmentation du recours au contrôle du rythme (rapport de cotes [RC] ajusté: 4.5; IC à 95 % : 1,8-11,6; p = 0,002) et une diminution de l'utilisation de médicaments servant à maîtriser la fréquence cardiaque (RC : 0,5; IC à 95 % : 0,2-0,9; p = 0,02). Aucun changement au chapitre des événements indésirables ni AVC ni décès n'a été signalé après 30 jours.

      Conclusions

      L'essai RAFF-3 a permis d'optimiser les soins prodigués aux patients à la suite d’épisodes de fibrillation ou de flutter auriculaires aigus. Ainsi, la durée du séjour au SU a diminué, le recours à des moyens de maîtrise du rythme cardiaque par médication ou cardioversion au SU a augmenté et aucune hausse des événements indésirables n'a été notée. La cardioversion précoce permet aux patients de reprendre rapidement leurs activités normales après un épisode de fibrillation ou de flutter auriculaires aigus.
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