Avoidable Admissions Research Articles

Strengthening the quality of primary healthcare services and interdisciplinary collaboration

Abstract Background Political organisations stress the need for preventive strategies to reduce the amount of avoidable hospital admissions, i.e. admissions that could have been avoided given timely and adequate care in the primary healthcare setting. Interdisciplinary collaboration has been suggested as a means to prevent hospitalizations, but effective implementation remains a challenge. Thus, there is a need for evidence-based strategies to prevent avoidable admissions and support interdisciplinary collaboration. The aim was to develop an evidence-based framework for preventive and coordinated interventions strengthening the quality of primary healthcare services and supporting interdisciplinary collaboration. Methods The project consists of three sub-studies: 1) a mixed methods systematic review following the JBI methodology; 2) a focus group study with primary healthcare providers in the Central Denmark Region, including general practitioners, physiotherapists, occupational therapists, home care providers, registered nurses and nurse specialists; and 3) a study using participatory design, where a framework for coordinated interventions were developed based on the results from study 1 and 2, supported by all stakeholders. Results Findings suggest that some hospitalizations can be prevented by intervening on mental factors, e.g., through trustful relations, and social factors, e.g., living situation. Also, a strong collaboration between healthcare providers from different disciplines and healthcare services is needed to improve the care pathway and prevent hospitalization. The collaboration may be strengthened if the health providers share a common language regarding the citizens’ health status. Conclusions Stakeholders at all levels should be informed about the relevance of considering mental, social and physical factors to improve the quality and responsiveness of primary healthcare services and to develop initiatives to support interdisciplinary collaboration. Key messages • By focusing on the whole person, it could be possible to provide more person-centred care through interdisciplinary collaboration and ultimately to prevent some admissions. • Well-established primary healthcare services are important to provide person-centred care through interdisciplinary collaboration.

Beliefs surrounding the use of inhaled asthma medication in The Gambia: a qualitative study of asthma patients and healthcare workers

Asthma-related mortality is high in low- and middle-income countries. Little is known about public perceptions of inhaled medicines. We conducted semi-structured interviews with asthma patients and healthcare workers at three secondary care facilities in The Gambia, between August and November 2022. Thematic analysis was used to interpret these data. A total of 20 patients and 15 healthcare workers were interviewed. Both groups noted limited access to inhalers was an issue resulting in continued use of oral medications. Some patients recognised the benefits of inhalers, yet beliefs that inhalers were dangerous were common. Reliance on oral short-acting beta agonists meant patients saw asthma as a recurrent acute condition resulting in an emphasis on hospital management with little awareness of inhaled preventative medicines. Increasing access to inhaled medicines has the potential to reduce costly avoidable admissions, but socio-cultural factors, in addition to medication supply, need addressing.

Long-term probabilistic forecasts of activity mitigation in English hospitals: a national elicitation exercise providing an outside view based on judgements of experts in support of the New Hospital Programme

ObjectivesThe planning process for a new hospital relies on assumptions about future levels of demand. Typically, such assumptions are characterised by point estimates, the flaw-of-averages, base-rate neglect and overoptimism from...

Weekly touch calls with high-risk cohort of patients with commercial Medicare Advantage to reduce avoidable hospital admissions.

282 Background: Patients who have been diagnosed with cancer have an increased risk of complications and potential hospitalization instances. Those in more advanced age groups have an additional risk, especially those of the age group of 65 and higher. Avoidable hospitalizations increase the total cost of care and decrease patient quality of life during treatment. Methods: To reduce potentially avoidable hospital admissions, patients enrolled in a commercial insurance contract were reviewed weekly for a high-risk potential. Criteria for high-risk inclusion included: Any patient >75 years of age receiving treatment; Any patient receiving chemotherapy/radiation combination therapy; Any patient with the following diagnosis: Metastatic lung cancer, Metastatic pancreatic cancer, Multiple myeloma, Breast cancer, Prostate cancer with multiple HCC; Any patient receiving: Cisplatin, Adriamycin, Taxanes, Ifosfimide, Doxorubicin, or Carbo with AUC 4 or greater; Any patient that has had one visit to ER/hospital during the program During the recording period, the high-risk list of patients was reviewed weekly. Before the weekend, each patient identified was contacted by phone by a registered nurse for a weekly “touch call” to address side effects, treatment questions, complications, or concerns. Patients were reminded to contact the practice first when a non-life-threatening concern occurs. Results: The program began on April 1, 2020, with a baseline admission rate of 1.8%. At the conclusion of the program on March 31st, 2023, this cohort of patients had a 53.1% reduction in admission rates from their baseline. Additionally, the reimbursement PPPM was under target yearly, concluding at $65.64, $14.46 below the target amount of $80. The cohort consisted of a range of 36-75 patients per quarter, program total of 185 enrolled patients. Conclusions: Identifying potentially high-risk patients and conducting weekly, personalized calls before the weekend reduced the overall avoidable admission rate. Timely identification and support for high-risk patients reduces the total cost of care and potentially increases patient care quality during treatment. Period Practice Inpatient Admits per 1000 Benchmark Target Target Difference Targeted Reimbursement PPPM Actual Reimbursement PPPM Reimbursement Difference 2020 Q1 1.8% 754 378 $80 2020 Q4 -17.9% 680 233 $80 $75.56 -$4.44 2021 Q4 -31.5% 622 3 $80 $66.66 -$13.34 2022 Q4 -51.3% 602 -235 $80 $65.64 -$14.46

Impact of Geriatricians on the Outcome of Patients in the Acute Medical Unit at the Largest Acute Academic Teaching Hospital

Abstract Background The Acute Medical Unit (AMU) forms part of our institution's acute medical pathways. Through the Senior Intervention Flow Triage system in our Emergency Department (ED), medically stable patients likely to complete investigations and treatment within 48 to 72 hours are referred to the AMU for management. Acute medicine geriatricians cover three out of five days in the AMU. This paper aims to study the characteristics and outcomes of patients referred to our AMU. Methods Our institution’s innovation and research office approved the study, ref: 8731, on 24/01/2024. Medical notes from patients who attended the AMU from 11 December 2023 to 30 January 2024 were examined. Collected data included demographics, presenting complaints, admissions avoided and converts. Patients were divided into age groups: ≤64, 65-74, and ≥75. Admission avoidance is any intervention by the AMU that results in the patient's discharge. A convert is an on-call team medically admitted patient in the ED who was taken over and successfully discharged by the AMU with appropriate follow-up. Results 345 patients attended AMU over the six-week period. Of those, 217 (62.9%) were ≤64, 65 (18.8%) were 65-74, and 63 (18.3%) were ≥75 years old. More than 50% of the patients were female in each age group. The ≤ 64 years group had the highest admission avoidance, 72%, followed closely by the ≥ 75 years group, 65% and the 65-74 years group, 57%. The ≥ 75 years group had the highest rate of converts at 11%, followed by the ≤ 64 years group at 10% and the 65-74 years group at 6%. There were similar admission rates across the 3 age groups of 7 to 8%. Conclusion This study found that the ≥ 75-year-old group was not inferior to other groups regarding admission rates and avoided hospital admissions.

Enhancing Physiotherapy Services within a Community Specialist Team for Older Adults: An Evaluation Study

Abstract Background An aim of Community Specialist Teams (CSTs) is to provide integrated multidisciplinary services to older people closer to home. Physiotherapy is a key component of this service. This evaluation aims to describe current physiotherapy practices within a specific CST and identify potential areas for improvement. The CST under examination maintains a physiotherapy staffing level of 1.2 Full-Time Equivalents. Methods An evaluation was completed of the physiotherapy input provided to 71 older adults who underwent a Comprehensive Geriatric Assessment (CGA) with the CST between July and December 2023. Data encompassing service user demographics and physiotherapy specific information were anonymised and analysed using Microsoft Excel. Results The median age of clients was 84 years (range 66-95), with 84.5% aged over 75 years. 70% were female. The median Clinical Frailty Scale (CFS) was 5 (range 3-7), with 75% being classified as frail. The reasons for referral were community rehabilitation (43%), admission avoidance (20%), early supported discharge (17%) and other (20%). Median time to CGA was 18 days (range 1-64 days). 64 (94%) patients were referred to physiotherapy and received an average of 4.4 sessions. Time to physiotherapy assessment following CGA ranged from 0-41 days with a median of 6 days. 83% of clients had physiotherapy intervention in their homes, 14% attended community hubs and 3% both. Analysis of delayed discharge revealed a range of 0-99 excess days beyond the estimated discharge date, with a median delay of 6 days. Conclusion This evaluation underscores the prevalent need for physiotherapy input among the service users engaged with this CST. Concerns arise regarding the breach of the of the National Integrated Care Programme for Older Persons (NICPOP) guideline for CGA timing (2 weeks) and target discharge date (6 weeks). The findings of this review will inform future service planning and the development of integrated physiotherapy pathways for older people.

Work of ART: Profiling the First 100 Patients Discharged Home From an Acute Hospital with the Active Recovery Team (ART)

Abstract Background The Active Recovery Team (ART) is a new therapy lead rehabilitation team that offers supported discharge and admission avoidance from a large acute hospital. This interdisciplinary team consists of a physiotherapist, occupational therapist, medical social worker and two therapy assistants. ART accepts referrals from all services within the hospital including the emergency department. Methods As ART is a new service, a retrospective audit of the first 100 patients who discharged on the pathway was completed. Demographics included age, sex, referring specialty, presenting complaint, frailty (measured by the Clinical Frailty Score) and level of input received. ART use the coding of low, medium and high intensity to describe the intervention provided based on dosage (visits) and complexity. Results Most (67%) of the group were female and mean age was 77 years. Only 8% were pre-frail (CFS 0-3), 86% were living with mild to moderate frailty (CFS 4-6) and 6% considered severely frail (CFS 7-9). The type of intervention patients received was 31% low, 33% medium and 36% high intensity. Referrals came from a range of specialties, but the highest percentage of referrals were from emergency medicine (29%), medicine (20%), orthopaedics (18%) and geriatric medicine (16%). Most (53%) initially presented post a fall at home. Most frequent reason for ART referral (78%) was that the patient was discharging home not at their functional baseline but had potential to an achieve a specific goal(s) with further input (most frequently within domains of mobility indoors/outdoors, transfers, stairs and activities of daily living). Conclusion This is an effective pathway that improves the transition from hospital to home. ART offer patients an opportunity for further rehabilitation at home with continuity of care from the acute hospital. Future work will examine the impact of ART on length of stay, readmission rate and explore patient satisfaction with this service.

The quality of home-based primary care delivered by nurse practitioners: A national Medicare claims analysis.

As the US population ages, there is an increasing demand for home-based primary care (HBPC) by those with Alzheimer's/dementia, multiple chronic conditions, severe physical limitations, or those facing end-of life. Nurse practitioners (NPs) are increasingly providing HBPC, yet little is known about their quality of care in this unique setting. This observational study uses Medicare claims data from 2018 to assess the quality of care for high-intensity HBPC users (5 or more visits/year) based on provider type (NP-only, physician (MD)-only, or both NP and MDs). We employ 12 quality measures from 3 care domains: access and prevention, acute care utilization, and end-of-life. Analysis includes bivariate comparisons and logistic regression models that adjust for demographic, clinical, and geographic characteristics. Among the 574,567 beneficiaries with 5 or more HBPC visits, 37% saw an NP, 37% saw a MD, and 27% saw both NPs and MDs. In multivariate models, those receiving HBPC from an NP or both NP-MD are significantly more likely to receive a flu shot than the MD-only group, but less likely to access preventive care. NP-only care is associated with more acute care hospitalizations, avoidable ED visits, and fall-related injuries, but significantly fewer avoidable admissions. For end-of-life care, those with NP-only or both NP-MD care are significantly more likely to have an advanced directive, be in hospice in the last 3 days of life, and more likely to die in hospice. The NP group is also more likely to die in the next year. HBPC patients are complex, with both palliative and curative needs. NPs provide almost half of HBPC in the Medicare program, to patients who are possibly sicker than those treated by physicians, with similar quality to MDs.

Avoidable admissions after minimally invasive hysterectomy

ObjectiveTo determine the rate of avoidable admissions following anticipated same-day discharge for patients undergoing minimally invasive hysterectomy and to identify risk factors associated with such admissions.MethodsA retrospective review was performed...

Understanding progression in multiple sclerosis: analysis of an in-patient admissions audit

Analysis of in-patient data is valuable to reduce avoidable admissions, which are disruptive to patients and costly to the NHS. The audit aimed to identify causes of in-patient admissions of people with multiple sclerosis at a district general hospital. The audit comprised a retrospective evaluation of secondary in-patient admissions data. Primary causes of admissions included chest infections, falls and urinary tract infections. Secondary progressive multiple sclerosis accounted for the largest number of admissions by multiple sclerosis sub-type, disproportionate to representation on the multiple sclerosis nurse caseload. In contrast, primary progressive multiple sclerosis was represented proportionally. Given the crossover between the two sub-types, this paper explores potential reasons for disproportionate representation by sub-type. Several factors may contribute to the admissions data by sub-type, including patient understandings of progression and information provided by clinicians. These findings have implications for the information and support provided by multiple sclerosis services.

How can health systems approach reducing health inequalities? An in-depth qualitative case study in the UK

BackgroundAddressing socioeconomic inequalities in health and healthcare, and reducing avoidable hospital admissions requires integrated strategy and complex intervention across health systems. However, the understanding of how to create effective systems to reduce socio-economic inequalities in health and healthcare is limited. The aim was to explore and develop a system’s level understanding of how local areas address health inequalities with a focus on avoidable emergency admissions.MethodsIn-depth case study using qualitative investigation (documentary analysis and key informant interviews) in an urban UK local authority. Interviewees were identified using snowball sampling. Documents were retrieved via key informants and web searches of relevant organisations. Interviews and documents were analysed independently based on a thematic analysis approach.ResultsInterviews (n = 14) with wide representation from local authority (n = 8), NHS (n = 5) and voluntary, community and social enterprise (VCSE) sector (n = 1) with 75 documents (including from NHS, local authority, VCSE) were included. Cross-referenced themes were understanding the local context, facilitators of how to tackle health inequalities: the assets, and emerging risks and concerns. Addressing health inequalities in avoidable admissions per se was not often explicitly linked by either the interviews or documents and is not yet embedded into practice. However, a strong coherent strategic integrated population health management plan with a system’s approach to reducing health inequalities was evident as was collective action and involving people, with links to a “strong third sector”. Challenges reported include structural barriers and threats, the analysis and accessibility of data as well as ongoing pressures on the health and care system.ConclusionWe provide an in-depth exploration of how a local area is working to address health and care inequalities. Key elements of this system’s working include fostering strategic coherence, cross-agency working, and community-asset based approaches. Areas requiring action included data sharing challenges across organisations and analytical capacity to assist endeavours to reduce health and care inequalities. Other areas were around the resilience of the system including the recruitment and retention of the workforce. More action is required to embed reducing health inequalities in avoidable admissions explicitly in local areas with inaction risking widening the health gap.

Avoidable emergency admissions: defining the concept.

The transfer of end-of-life patients to hospital via admission to an emergency service mainly happens because of a lack of community support nearby and a lack of resources in palliative care. This study aimed to define the concept of avoidable admission to an emergency department for palliative patients. An integrative literature review was performed. The results of this were put to a panel of palliative care experts via a Delphi process to determine their consensus and agreement with the statements. The results of the two-step Delphi process reached a high level of consensus and agreement that patients with palliative needs accompanied by home palliative care teams should not go to the emergency department. There was a low level of consensus and agreement about the appropriate admission of a patient in pain in the absence of any information about previous community support. The findings allowed the definition of an 'avoidable emergency admission', which is an emergency admission for any symptom or condition that could be supported in a home context or primary health care, or any emergency admission that does not require immediate nursing or medical intervention, nor leads to greater comfort or quality of life for the patient.

Are local public expenditure reductions associated with increases in inequality in emergency hospitalisation? Time-series analysis of English local authorities from 2010 to 2017

BackgroundReductions in local government funding implemented in 2010 due to austerity policies have been associated with worsening socioeconomic inequalities in mortality. Less is known about the relationship of these reductions...

Making a case for outpatient parenteral antimicrobial therapy (OPAT).

In the wake of the COVID-19 pandemic, and its negative impact on both acute and elective care and decline in available inpatient resources, there is an imperative to maximize safe and effective alternatives to inpatient hospital care. Properly governed outpatient parenteral antimicrobial therapy (OPAT) services embed the principles of antimicrobial stewardship (AMS) (including use of early oral therapy) and support admission avoidance and early discharge for a growing range of patient groups with complex infections through well-organized multidisciplinary team working. Expansion of OPAT aligns with the UK's national strategy to deliver care closer to home and cost-effectively maximize use of inpatient resources. OPAT serves as an exemplar to other ambulatory services and presents opportunities for developing and assuring AMS strategies within the rapidly developing hospital-at-home and virtual ward environments.

Clinical outcomes in OPAT patients treated with ceftriaxone 4 g and ceftazidime 6 g extended interval dosing regimens.

New dosing regimens for ceftriaxone 4 g/24 hours and ceftazidime 3 g/12 hours are convenient for patients receiving OPAT. To date, these have not been clinically validated. To assess the tolerability, toxicity and effectiveness of once daily ceftriaxone (4 g) and 12 hourly ceftazidime regimens (3 g twice a day) in the OPAT setting. From April 2018 until March 2023; demographic, clinical, microbiological and outcome data were collected on all adult patients discharged to a community-based OPAT team in East London. There were 487 OPAT episodes. Fifty-three (10.9%) patients received ceftriaxone 4 g once a day and 20 (4.1%) ceftazidime 3 g twice a day. In the ceftriaxone group, the commonest conditions treated were orthopaedic, neurosurgical or diabetic foot infections. OPAT was used to expedite the discharge of 45 (84.9%) patients, the remainder were admission avoidance episodes. The commonest isolate causing infection was MSSA 23 (43.4%). There were no tolerability or toxicity episodes recorded. All patients were cured and bed days saved were 1266.In the smaller twice-daily ceftazidime cohort, seven (35%) patients were treated for necrotizing otitis externa, six (30%) for bronchiectasis and six (30%) for urinary tract infections. The commonest cause of infection was P. aeruginosa, 18 (90%). One case of nephrotoxicity was recorded. All patients were cured and bed days saved were 896. Regimens of ceftriaxone 4 g once a day and ceftazidime 3 g twice a day were well tolerated and highly effective. If widely adopted, these regimens will save OPAT and nursing time and enable more patients to be treated.

Virtual Medicine Wards and Hospital-at-Home Programs

What Is the Issue? In 2021, the occupancy rate of acute care hospital beds in Canada was 86.7%. High occupancy rates without turnover to accommodate all hospitalization needs is an indicator of potential bed shortages and health system pressure. Patients have historically remained in hospital beds until their treatment or recovery is complete. Some patients may be well enough to continue their treatment or recovery at home sooner if provided with the right supports. What Are the Technologies? Virtual wards, also known as hospital-at-home programs, support the provision of inpatient-level acute medical care in a patient’s home. There are 2 main models of these programs: admission avoidance and supported early discharge. This report focuses on the latter type. Many of these programs are technology-enabled and incorporate remote monitoring devices to record the patient’s vital signs and tablets or web portals to facilitate data sharing. Video calls with the clinical team are also used in combination with in-person visits by health care providers. What Is the Potential Impact? Hospital beds can be freed up more quickly to provide space for newly admitted patients with more acute care needs. The safety and effectiveness of virtual ward programs have been examined in several systematic reviews in the existing clinical literature. Factors evaluated include mortality, length of stay, hospital readmissions, and costs as outcomes. Both admission avoidance and early supported discharge via hospital-at-home programs had lower or similar mortality and hospital admission outcomes as inpatient care after completion of care. Patients, caregivers, and health care providers appear to be generally satisfied with their participation in virtual ward programs. Comfort and satisfaction can be improved by allowing patients to receive treatment in a familiar and comfortable environment without compromising patient outcomes. However, increased caregiver burden, lack of sufficient training for participants and staff, and difficulties recruiting health care providers were identified as challenges associated with virtual ward programs. What Else Do We Need to Know? The level of technological support required by patients, caregivers, and staff participating in these programs should be considered when developing a program. Adequate training about how to use provided equipment and other tasks needed to manage care in the home (e.g., drug administration, symptom monitoring, communication with health care professionals) is required for patients and caregivers. There should also be provision of all necessary equipment with supports to overcome any barriers (e.g., visual impairment, physical limitations) to ensure comfort and proficiency. Care coordination and communication among the multidisciplinary care team, the patient, and their caregivers is important. Canadian cost data were not identified, but it is generally accepted that virtual ward programs are associated with reduced costs when compared with traditional in-hospital care. The inclusion of digital monitoring and record keeping technologies as part of virtual ward programs may disproportionately exclude people from some groups, including older people, people living in social housing or without housing, people with lower incomes, people who are unemployed, people living with disabilities, and people who live in rural areas without access to such programs. Key recommendations for development of virtual ward programs in Canada include using a single remote patient-monitoring platform that connects with the hospital’s electronic health record system, choosing a technology to connect patients and providers that best fits the needs of the virtual ward program, and ensuring data security, confidentiality, and data management protocols are in place.

Economic cost-benefit analysis of person-centred medicines reviews by general practice pharmacists

BackgroundMedicines reviews by general practice pharmacists improve patient outcomes, but little is known about the associated economic outcomes, particularly in patients at higher risk of medicines-related harm.AimTo conduct an economic cost-benefit analysis of pharmacists providing person-centred medicines reviews to patients with hyperpolypharmacy (prescribed ≥ 10 regular medicines) and/or at high risk of medicines-related harm across multiple general practice settings.MethodService delivery costs were calculated based on the pharmacist’s salary, recorded timings, and a general practitioner fee. Direct cost savings were calculated from the cost change of patients’ medicines post review, projected over 1 year. Indirect savings were calculated using two models, a population-based model for avoidance of hospital admissions due to adverse drug reactions and an intervention-based model applying a probability of adverse drug reaction avoidance. Sensitivity analyses were performed using varying workday scenarios.ResultsBased on 1471 patients (88.4% with hyperpolypharmacy), the cost of service delivery was €153 per review. Using the population-based model, net cost savings ranging from €198 to €288 per patient review and from €73,317 to €177,696 per annum per pharmacist were calculated. Using the intervention-based model, net cost savings of €651–€741 per review, with corresponding annual savings of €240,870–€457,197 per annum per pharmacist, were calculated. Savings ratios ranged from 181 to 584% across all models and inputs.ConclusionPerson-centred medicines reviews by general practice pharmacists for patients at high risk of medicines-related harm result in substantial cost savings. Wider investment in general practice pharmacists will be beneficial to minimise both patient harm and healthcare system expenditure.

Impact of first-line dalbavancin for cellulitis on hospital admissions and costs: A case series

BackgroundMany patients with cellulitis are treated with oral antibiotics as outpatients, but some require hospital admission for intravenous antibiotics. During the coronavirus disease 2019 pandemic, Betsi Cadwaladr University Health Board in Wales approved use of dalbavancin as first-line intravenous antibiotic from April to December 2020 to facilitate early discharge and prevent hospital admission. ObjectivesTo report cost savings and admission avoidance through first-line intravenous use of dalbavancin for cellulitis in one health board in Wales. Patients and methodsPatients with cellulitis who presented to the emergency department or medical assessment unit at Betsi Cadwaladr University Health Board's two hospitals between April and December 2020 were identified for treatment with dalbavancin, because they had not responded to oral antibiotics or their initial presentation warranted intravenous antibiotics. Patients received 1500 mg dalbavancin by intravenous infusion according to prescribing information and were sent home without being admitted. Outcomes were admission within 30 d of dalbavancin and cost savings from avoiding admission. Results31 patients were treated with dalbavancin for cellulitis in the emergency department or medical assessment unit. No patient was admitted within 30 d of receiving dalbavancin. Use of dalbavancin is estimated to have saved 248 bed-days over the study period, with an estimated saving of $120,444.23 based on avoidance of admission. The cost of dalbavancin for these 31 patients was $69,959.08, giving an overall cost saving of $50,485.15 ($1529.95 per patient). ConclusionsPrescribing dalbavancin as first-line intravenous antibiotic for cellulitis prevents admission, saving bed-days and admission-related costs.

Palliative care inpatients in Switzerland (2012–2021): characteristics, in-hospital mortality and avoidable admissions

ObjectivesPalliative patients generally prefer to be cared for and die at home. Overly aggressive treatments place additional strain on already burdened patients and healthcare services, contributing to decreased quality of...

Comprehensive atrial fibrillation package of care to minimise unnecessary hospital admission and improve patient outcome: a quality improvement project

Abstract Funding Acknowledgements None. Introduction Recent studies have highlighted an increasing rate of hospitalisation among atrial fibrillation (AF) patients, despite a relatively low in-hospital mortality rate. This trend carries significant financial implications, with a twofold increase in AF-related expenditures, over 50% of which are associated with inpatient care. Purpose A Quality Improvement Project (QIP) was conducted to enhance AF care, reduce unnecessary admissions, and address the root causes driving increased hospitalisations. Methods The root cause analysis, illustrated in Figure 1, revealed four factors contributing to the increased hospital admission rate of newly diagnosed AF patients: systemic issues, the nature of the disease itself, patient and physician-related factors. The driver diagram (Figure 2) visually presented the primary and secondary drivers with corresponding interventions targeting potential areas for improvement. Plan, Do, Study, Act (PDSA) cycle was conducted using four-pronged approach: 1. Updating local guidelines and designing a stepwise algorithm to align with contemporary standards of care. 2. Establishing an ambulatory care/arrhythmia clinic referral pathway for follow-up of stable AF patients to ensure continuity of care, thus minimizing unnecessary admissions. 3. Implementing a safe discharge toolkit comprising patient education materials, a poster for stroke and bleeding risk assessment tools, and an anticoagulation checklist. 4. Incorporating AF management teaching sessions into the doctors’ induction curriculum to enhance their knowledge and confidence in managing newly diagnosed AF patients and ensuring safe discharges. Results Lack of an ambulatory care or arrhythmia clinic referral pathway, inadequate educational resources, insufficient clinician training were key factors contributing to unwarranted hospitalization of newly diagnosed AF patients. The comprehensive guideline revision process, requiring substantial resources and the support of stakeholders and a multidisciplinary team comprising cardiologists and emergency and acute medical physicians, facilitated the successful implementation of the new AF referral pathway. This QIP resulted in a 16% reduction in avoidable admissions, 24% increase in clinician confidence, and 18% improvement in adherence to stroke and bleeding risk assessment protocols, in addition to reducing the hospital stay duration. Conclusions The collaboration among diverse medical disciplines, evidence-based guideline revision, and the implementation of a streamlined AF referral pathway demonstrated the potential to reduce healthcare resource utilization and financial burdens. This approach aligns with national standards, enhances healthcare providers' knowledge and confidence, ensuring standardised clinical practices. It underscores its potential for implementation of similar pathways to improve patient care. Continuous evaluation to evolving guidelines are recommended for sustainability.Figure 1.Ishikawa fishbone diagramFigure 2.Driver diagram for AF care