SOCIAL MEDIA Hot Off the Press: A Novel Algorithm to Decrease Unnecessary Hospitalizations in Patients with Atrial Fibrillation Justin Morgenstern, MD, Corey Heitz, MD, Chris Bond, MD, and William K. Milne, MD BACKGROUND A trial fibrillation (AFib) is the most common dys- rhythmia encountered in the emergency depart- ment (ED). 1 However, the management of AFib is incredibly variable. 2,3 In the United States, most patients presenting to the ED in AFib are admitted to hospital, accounting for a large proportion of the costs associated with this condition. 4–6 However, in other countries, such as Canada, the vast majority of AFib patients are managed as outpatients. 2 Inpatient care is more expensive, but allows for a more rapid workup. It is unclear which patients require admission for AFib and which can be managed safely as outpatients. The objective of this study was to determine whether the implementation of a new algorithm for patients with a primary diagnosis of AFib could safely decrease the hospital admission rate. ARTICLE SUMMARY This is a retrospective cohort study with a before-and- after design, comparing the admission rate for patients with AFib during a 1-year period before the initiation of a new management algorithm to a 1-year period after the algorithm was introduced. Physicians were first instructed to determine whether the AFib was secondary to another important diagnosis, such as sep- sis or pulmonary embolism. (These patients were admitted to hospital.) Among the patients with pri- mary AFib, physicians assessed for four high-risk crite- ria: hemodynamic instability, acute heart failure, syncope, and acute coronary syndrome. Patients with no high-risk criteria were managed with either rate or rhythm control and then discharged home with close outpatient follow-up. The admission rate for AFib patients fell from 80% in the before period to 67% after, with no change in ED return visits. QUALITY ASSESSMENT There are a number of limitations inherent to the before-and-after study design. Any observational study is at risk of unseen confounders. There is a general trend toward cutting costs and decreasing admissions in medicine, which could explain some of the decrease in admissions seen in this study. Similarly, the Hawthorne effect—where individuals change their behavior because they know they are being observed— could also have contributed to the observed changes. It may be difficult to duplicate the results of this study, because we are not provided with details about how clinicians were educated about and encouraged to From the University of Toronto (JM), Toronto, Ontario, Canada; the Virginia Tech Carilion School of Medicine (CH), Roanoke VA; the University of Calgary (CB), Calgary, Alberta, Canada; and the University of Western Ontario (WKM), Goderich, Ontario, Canada. Received July 8, 2018; accepted July 9, 2018. Discussing: DeMeester S, Hess RA, Hubbard B, LeClerc K, Ferraro J, Albright JJ. Implementation of a novel algorithm to decrease unnecessary hospitalizations in patients presenting to a community emergency department with atrial fibrillation. Acad Emerg Med 2018;25:641–9. Associated podcast: http://thesgem.com/2018/06/sgem222-rhythm-is-gonna-get-you-into-an-atrial-fibrillation-pathway/. The authors have no relevant financial information or potential conflicts to disclose. Supervising Editor: Esther K. Choo, MD, MPH. Address for correspondence and reprints: Justin Morgenstern, MD; e-mail: Justin.Morgenstern@gmail.com. ACADEMIC EMERGENCY MEDICINE 2018;25:1284–1286. 1284 ISSN 1553-2712 © 2018 by the Society for Academic Emergency Medicine doi: 10.1111/acem.13514