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

Abstract

BACKGROUND\nWe sought to improve care of patients with acute atrial fibrillation (AF) and flutter (AFL) in the emergency department (ED) by implementing the CAEP AAFF Best Practice Checklist.\n\n\nMETHODS\nWe conducted a stepped-wedge cluster randomized trial at 11 large community and academic hospital EDs, in five Canadian provinces and enrolled consecutive AF/AFL patients. The study intervention was the introduction of the CAEP Checklist using a knowledge translation-implementation approach that included behavior change techniques and organization/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.\n\n\nRESULTS\nPatient visits in the control (N=314) and intervention (N=404) periods were similar with mean age 62.9, 54% male, 71% onset <12 hours, and 86% atrial fibrillation, 14% atrial flutter. We observed a reduction in length of stay of 20.9% (95% CI 5.5 to 33.8%, P=0.01), an increase in use of rhythm control (adjusted odds ratio (OR 4.5, 1.8-11.6; P=0.002), and decrease in use of rate control medications (OR 0.5, 0.2 to 0.9; P=0.02). There was no change in adverse events and no strokes or deaths by 30 days.\n\n\nCONCLUSIONS\nThe RAFF-3 Trial led to optimized 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. CLINICALTRIALS.\n\n\nGOV IDENTIFIER\nNCT03627143.