Abstract 18766: Optimizing Stroke Prophylaxis in the Emergency Department With an Electronic Clinical Decision Support Tool: A Preliminary Analysis of a Multi-Stage Multi-Center Stepped-Wedge Cluster Randomized Trial

Abstract

BACKGROUND: Atrial fibrillation (AF) is a common arrhythmia that is often first diagnosed in the Emergency Department (ED). AF is associated with an increased risk of stroke that can be reduced by 64% if an oral anticoagulant (OAC) is prescribed appropriately. RESEARCH QUESTION: Will education and implementation of a clinical decision support (CDS) tool in the ED increase OAC prescription for appropriate candidates diagnosed with new-onset or paroxysmal AF (pAF)? METHODS: This is the first phase of a multi-stage multi-center stepped-wedge cluster-randomized clinical trial implementing a CDS tool into the electronic health record (EHR). Step one implements an external browser link to the CDS tool in the EHR with targeted provider education, whereas steps 2 and 3 will motivate provider engagement with triggers. Data were collected from an urban academic tertiary care center and a community hospital. Patients aged greater than 17 years were selected if they had a primary diagnosis of AF/pAF during ED visits from Jan 2020-Apr 2023. The academic and community sites transitioned from the retrospective phase to Step 1 in Jan 2022 and Apr 2022, respectively. Appropriate OAC prescription was determined based on elevated stroke risk and low-moderate bleed risk. A logistic GEE model was used to study the effect of the proposed intervention on OAC prescription. ED providers were treated as a random effect to capture clustering. The model includes the CDS intervention, site, and patient characteristics sex, race, ethnicity, and age. RESULTS: Of 2031 patients, 312 met inclusion criteria and 150 were selected as appropriate OAC candidates, with 72 (52% male, median age 74) in the retrospective step and 78 (52% male, median age 76) in Step 1. Below are odds ratio estimates with corresponding 95% CI’s: CDS intervention 3.12 [1.57, 6.21] and sex female vs male 2.04 [1.04, 4.00]. Non-significant variables site, race, ethnicity, and age were included as adjusting covariates. CONCLUSIONS: Limited CDS tool education and integration is associated with improved OAC prescribing for appropriate AF/pAF patients. Future studies should assess the impact of additional CDS integration on OAC prescribing and patient outcomes.