Keeping the “P’s”: Instituting Risk Assessment in New-Onset Postoperative Atrial Fibrillation Prevention

Background: Approximately one third of cardiac surgical patients develop new-onset atrial fibrillation. The direct myocardial and reperfusion injuries caused by cardiac surgery makes patients more prone to developing atrial fibrillation. Its occurrence following surgery can lead to multiple adverse outcomes including hemodynamic instability and decreased cardiac output. Postoperative atrial fibrillation, or POAF, also contributes to prolonged intensive care unit and hospital lengths of stay. The CHA2DS2-VASc score has been found to be a valid and reliable tool for predicting atrial fibrillation in the postoperative period. The purpose of this practice change was to have advanced practice providers utilize a practical tool for risk stratifying postsurgical cardiac patients for POAF and encouraging their use of best practices for the arrhythmia’s prevention. Methods: The proposed practice change took place over 12 weeks and focused on the advanced practice providers within the intensive care unit of a local university hospital. The Theory of Planned Behavior was used to support the planning and implementation of the practice change. Providers received education, reference materials and evidence supporting the use of the CHA2DS2-VASc score for POAF risk stratification following coronary artery bypass grafting, valve procedures, or concomitant surgeries. Audits of the electronic medical record were performed to evaluate providers’ application of the practice change into practice, or fidelity. Logistical regression was used to find a statistically significant relationship between the CHA2DS2-VASC score and the development of POAF. Result: Thirty-five, or 92.1% of cardiac surgery patients undergoing coronary artery bypass grafting, valve procedures or concomitant surgeries were risk stratified by advanced practice providers using the CHA2DS2-VASc scoring tool. The CHA2DS2-VASc score predicted the occurrence of POAF (p=0.023) following CABG and/or valvular surgeries. Patients were more likely to develop atrial fibrillation as the CHA2DS2-VASc score increased (OR 1.025, 95% CI 1.151 – 6.748). Implications for Practice: A risk stratification model may help encourage safer, more consistent provider practices and shift efforts from treatment to prevention of postoperative atrial fibrillation. Efforts to prevent new-onset atrial fibrillation can indirectly decrease the occurrence of adverse outcomes (e.g., hemodynamic instability) therefore improving patient care and safety standards within the intensive care unit.Doctor of Nursing Practic