Adoption of a single-page best practice algorithm improves outcomes in patients with acute atrial fibrillation: a multi-disciplinary quality improvement project

Document Type : Original Article


1 Queen Mary University,London,United Kingdom.

2 North Middlesex University Hospital, London, United Kingdom.


Introduction: In response to a serious incident involving an atrial fibrillation (AF) associated stroke, a quality improvement project was established to examine and improve all aspects of patient care for individuals presenting with acute AF to London’s North Middlesex University Hospital (NMUH).
Materials and Methods: The presenting complaint was examined for 2,105 consecutive medical admissions to identify 100 patients (4.7%) with acute AF. For each patient, 36 indices and performance indicators were collected and analysed against international standards. Deficiencies were identified in documentation, risk stratification, anticoagulation and arrhythmia management decisions. With cross-specialty collaboration, a single-page AF management algorithm was established using sequential PDSA methodology, and a further 100 consecutive patients with acute AF were analysed prospectively. A composite end-point of adverse outcomes (AF-associated readmission, stroke, cardiac death or major bleeding) was examined.
Results: Algorithm implementation significantly reduced the proportion of patients exposed to unnecessary stroke risk (30% vs 4%, p<0.0001); improved identification and documentation of thromboembolic potential (50% vs 88%, p<0.0001), reduced incorrect drug decisions (12% vs 2%, p=0.01), reduced contraindicated rhythm control (8% vs 0%, p=0.007), and increased direct oral anticoagulant (DOAC) prescribing (38% vs 86%, p<0.0001) over warfarin. After a mean follow-up of 248 +/- 91 days, there was a significant reduction in composite adverse outcomes (22% vs 6%, p=0.0018).
Conclusion: Using established quality improvement methodology and cost-neutral multi-disciplinary expertise, this novel management algorithm has significantly improved the quality and safety of care for patients with acute AF at NMUH.


Main Subjects

  1. Rahman F, Kwan GF, Benjamin EJ. Global epidemiology of atrial fibrillation. Nat Rev Cardiol. 2014; 11(11):639-54.
  2. Friberg L, Rosenqvist M, Lindgren A,  Terént A, Norrving B, Asplund K. High prevalence of atrial fibrillation among patients with ischemic stroke.Stroke 2014.45(9):
  3. Kirchhof PBenussi SKotecha D, Ahlsson AAtar DCasadei B et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS Eur Heart J 2016 37(38):2893-2962.
  4. National Institute for Health and Care Excellence Atrial Fibrillation: Management, Clinical Guideline 180, June 2014.
  5. Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PC et al. Why don’t physicians follow clinical practice guidelines? JAMA 1999 282(15):1458-65.
  6. Shariff N, Aleem A, Singh M, Li YZ, Smith SJ AF and Venous Thromboembolism – Pathophysiology, Risk Assessment and CHADS-VASc score J Atr Fibrillation. 2012 5(3): 649.
  7. Lip GYH,  Frison L, Halperin JL and Lane DA Comparative Validation of a Novel Risk Score for Predicting Bleeding Risk in Anticoagulated Patients With Atrial Fibrillation J Am Coll Cardiol. 2011 57(2): 173-80
  8. Potpara TS; Lane DA; Lip GY Optimizing stroke prevention in atrial fibrillation: better adherence and compliance from patients and physicians leads to better outcomes Europace 2015 17(4):507-8
  9. Granger CB, Lopes RD, Hanna M, Ansell J, Hylek EM, Alexander JH et al. Clinical events after transitioning from apixaban versus warfarin to warfarin at the end of the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) trial. Am Heart J. 2015 169(1):25-30.
  10. ROCKET AF Study Investigators. Rivaroxaban-once daily, oral, direct factor Xa inhibition compared with vitamin K antagonism for prevention of stroke and Embolism Trial in Atrial Fibrillation: rationale and design of the ROCKET AF study. Am Heart J.2010 159(3):340-7.
  11. Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, M.D., Parekh A et al. Dabigatran versus Warfarin in Patients with Atrial Fibrillation. N Engl J Med 2009 361:1139-1151.
  12. Bai Y, Shi X,  Ma C, Lip GYH Meta-Analysis of Effectiveness and Safety of Oral Anticoagulants in Atrial Fibrillation With Focus on Apixaban The American Journal of Cardiology 2017 120(9): 1689-1695
  13. Pisters R, van Oostenbrugge RJ, Knottnerus ILH, de Vos CB, Boreas A, Lodder J et al. The likelihood of decreasing strokes in atrial fibrillation patients by strict application of guidelines Europace 2010 12: 779–784
  14. Xian YO'Brien ECLiang LXu HSchwamm LHFonarow GC et al. Association of Preceding Antithrombotic Treatment With Acute Ischemic Stroke Severity and In-Hospital Outcomes Among Patients With Atrial Fibrillation. JAMA. 2017 317(10):1057-1067
  15. Vallakati A, Lewis WR Underuse of anticoagulation in patients with atrial fibrillation Postgrad Med. 2016;128(2):191-200
  16. Palomäki AMustonen PHartikainen JENuotio IKiviniemi TYlitalo A Underuse of anticoagulation in stroke patients with atrial fibrillation – the FibStroke Study Eur J Neurol. 2016 23(1):133-9
  17. Brown JDShewale ARDherange PTalbert JC.  A Comparison of Oral Anticoagulant Use for Atrial Fibrillation in the Pre- and Post-DOAC Eras. Drugs Aging. 2016 33(6):427-36.
  18. López-López JASterne JACThom HHZHiggins JPTHingorani ADOkoli GNet al. Oral anticoagulants for prevention of stroke in atrial fibrillation: systematic review, network meta-analysis, and cost effectiveness analysis. BMJ. 2017 359:j5058
  19. Basto ANFewel NPVo KStock EMTa M. Initiation of direct oral anticoagulants versus warfarin for venous thromboembolism: impact on time to hospital discharge. J Thromb Thrombolysis. 2018 45(1):51-55
  20. Bhattarai MHudali TRobinson RAl-Akchar MVogler CChami Y Impact of oral anticoagulants on 30-day readmission: a study from a single academic centre. BMJ Evid Based Med. 2019 24(1):10-14.