With the goal of making our treatment recommendations readily available to physicians at the point of care, we designed a web-based clinical decision support system (CDSS), called RISTRA-AF (RISTRA stands for Risk Stratification). By promoting stroke prevention actions, we sought to increase the 30-day incidence of anticoagulation initiation for eligible patients. By improving rate reduction and cardioversion, we sought to reduce hospitalization in patients with isolated AF or atrial flutter, at least in medical centers with higher hospitalization rates. Using recommendations from various clinical practice guidelines, as well as from primary studies and internal best practices, we created a set of recommendations for emergency medicine physicians in our integrated healthcare delivery system, addressing three leading aspects of ED care: (1) achieving sustained rate reduction for patients with rapid ventricular response (2) optimizing cardioversion by increasing first-shock success or using suitable pharmacologic agents (3) increasing implementation of stroke prevention actions in eligible patients being discharged home. But professional society-based guidelines for AF treatment vary in the amount of attention given to emergency medicine-related issues and offer variable recommendations for acute management. Implementation of professional society-based guidelines may help standardize care around best practices. Treatment strategies vary widely between countries, within countries, and within facilities. There is no definitive evidence supporting optimal ED management of patients with AF and atrial flutter. Patients with symptomatic AF and atrial flutter often present to the emergency department (ED) for treatment. The economic burden on the health care system is considerable. These atrial arrhythmias have a substantial impact on quality of life and patient health, increasing the risk for heart failure, thromboembolism, hospitalization, and death. Registered on 17 August 2021.Ītrial fibrillation (AF) and atrial flutter are prevalent in the USA and are likely to escalate as the population continues to age. If our hypotheses are confirmed, the treatment protocol and CDSS could be recommended to other EDs to improve management of adults with AF or atrial flutter. We hypothesize that the CDSS intervention will reduce hospitalization of adults with isolated AF or atrial flutter presenting to the ED and increase anticoagulation prescription in eligible patients at the time of ED discharge and within 30 days. We will evaluate the impact of the CDSS on hospitalization and stroke prevention actions using a stepped-wedge cluster randomized pragmatic clinical trial across 13 community EDs in Northern California. We implemented the CDSS at three pilot sites to assess feasibility and solicit user feedback. We also describe the development of an electronic clinical decision support system (CDSS) to deliver these recommendations to emergency physicians at the point of care. We describe the rationale for our ED-based AF treatment recommendations. Standardization using evidence-based recommendations could reduce variation in management, preventable hospitalizations, and stroke risk. Different approaches to these components of care may lead to variation in frequency of hospitalization and stroke prevention actions, with significant implications for patient experience, cost of care, and risk of complications. Management of adults with atrial fibrillation (AF) or atrial flutter in the emergency department (ED) includes rate reduction, cardioversion, and stroke prevention. on behalf of the Kaiser Permanente CREST Network.Clinical decision support to Optimize Care of patients with Atrial Fibrillation or flutter in the Emergency department: protocol of a stepped-wedge cluster randomized pragmatic trial (O’CAFÉ trial)
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