Evaluating the effect of an emergency department protocol and early outpatient follow up in a specialised clinic for atrial fibrillation

There are two components to the intervention: 1. An emergency department protocol for the management of atrial fibrillation (AF). This protocol will aim to guide emergency department clinicians in the acute management of AF to standardise care delivery, provide appropriate anticoagulation to reduce stroke risk and written advice for patients on management of the current or recurrent episodes of AF. This emergency department protocol has been developed by a multidisciplinary team including electrophysiologists, emergency department physicians, emergency department nurses and specialist atrial fibrillation nurses. The protocol has been presented and refined following presentation to a specialist group of electrophysiology researchers (Centre for Heart Rhythm Disorders) and the emergency department team at the Royal Adelaide Hospital. The protocol will be evaluated at the same time as the rapid access AF clinic, as this clinic is an integral part of the protocol. 2. All intervention participants will be asked to return to the hospital within 24-72 hours from their emergency department presentation to attend a rapid access AF clinic. This clinic will be staffed by a specialist cardiology nurse and electrophysiology fellow or consultant. The nurse will receive training in the use of structured educational visiting, a technique designed to educate and empower the patient with use of key messages deemed essential to facilitate self management of their condition. Delivery of this education will be supported by a validated written patient resource, Living Well with Atrial Fibrillation. This resource was previously developed and evaluated in another research study undertaken by our group (Home Based Education and Learning Program for Atrial Fibrillation) and was published in 2019. In addition to this education, other care provided in this clinic will include referral for electrical cardioversion (if required), referral for other investigations in these have not been performed in the last 12 months, including holter monitoring, echocardiography, blood testing and exercise stress testing and provision of advice for the future management of AF episodes. The appropriate use of medication to manage AF, including oral anticoagulation to manage stroke risk and rate and rhythm controlling agents will be prescribed as required. Relevant comorbidity management will also be assessed with referral to other healthcare professionals permitted if indicated. This initial visit will be followed up by one follow up visit four to six weeks later to re-enforce education provided and review any test results. The initial visit is expected to last for 60-90 minutes with the second visit expected to take 30-60 minutes. Following this second visit, care will be returned to the treating General Practitioner and Cardiologist. A letter will be sent to the General Practitioner and Cardiologist summarising each visit. If patients re-present to hospital with atrial fibrillation or flutter over follow up, they will be managed with the emergency department protocol if they meet the inclusion and exclusion criteria. One extra follow up visit will be undertaken in the rapid access AF clinic to address any potentially modifiable factors associated with repeat hospital presentations. This will be scheduled to occur within 24-72 hours as per the standard protocol. Adherence to the protocol will be evaluated through audit of medical records. This will be recorded in the research database. Adherence to the rapid access AF clinic protocol will be ensured through practitioner training and oversight by senior research members. A checklist will be utilised in the research database to ensure that all required clinic components are adhered to.