University of Northern Colorado
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University of Northern Colorado
Patients, especially those older than 65-years-old, do not receive adequate assessment or management of atrial fibrillation, resulting in higher ischemic stroke rates and worse outcomes related to strokes. Oral anticoagulation is recommended indefinitely for patients with atrial fibrillation and a moderate to high risk of stroke; yet this population is not receiving oral anticoagulation consistently. Factors such as overexaggerated bleeding risk in the elderly, the lack of head-to-head studies comparing anticoagulants, cost, patient compliance, safety, lab monitoring, and reversal agents convolute the process of prescribing anticoagulation for atrial fibrillation. Variations exist with assessing bleeding risk and stroke risk for every patient through reliable tools such as HAS-BLED and CHA2DS2-VASc scores, respectively, and translating these scores into practice. Due to these inconsistencies and the lack of a comprehensive, universal guideline for assessment and management of atrial fibrillation, this topic was selected for a capstone project. A retrospective chart review was completed on 100 patients to assess the current practice of diagnosing atrial fibrillation and treating with anticoagulation in the primary care setting. Through utilization of two rounds of the Delphi method, expert opinion, and the recommendations of national and international guidelines, an evidence-based anticoagulation toolkit was created and modified to guide primary care providers on improving diagnosis of atrial fibrillation and enhanced initiation and maintenance of oral anticoagulation to reduce the incidence of stroke in elderly patients with atrial fibrillation. The Anticoagulation for Atrial Fibrillation Toolkit is a four-step, simplified guideline to guide providers on improved diagnosis and treatment of AF; it is supported by four algorithms: CHA2DS-VASc score, HAS-BLED score, comparison of anticoagulants, and patient specific factors influencing selection of anticoagulant. Additionally, this toolkit offers in one document a summary of additional information and resources for providers to improve the overall management of atrial fibrillation. The chart reviews demonstrated gaps between evidence and practice, predominantly a lack of utilization of CHA2DS2 VASc and HAS-BLED scores to assess for stroke and bleeding risk, respectively, in patients with atrial fibrillation, poor continued monitoring of AF in the primary care setting, a disconnect between the treatment plan and providers, and the absence of consistently diagnosing an irregular pulse as AF through an EKG. Round 1 of the Delphi survey assessed providers’ comfort level and expertise with prescribing anticoagulants and diagnosing and managing AF and Round 2 evaluated the anticoagulation toolkit and how its incorporation could influence practice. Results from Round 1 were utilized to revise the evidence-based anticoagulation toolkit; data analysis concluded 70% consensus was achieved on at least 6 of the 10 questions. Even without 70% consensus, the researcher incorporated provider expertise, suggestions, and requests into the anticoagulation toolkit. In Round 2, data analysis of greater than 70% consensus suggested the Anticoagulation for Atrial Fibrillation Toolkit was evidence based, user-friendly, promoted safety and efficacy of anticoagulation, and could positively impact practice; however, the toolkit was too extensive and lengthy. A thorough evaluation concluded this capstone project successfully addressed the following problem statement: In adult patients with atrial fibrillation older than 65 years old and a moderate to high risk of stroke, how effective is an anticoagulation toolkit in guiding primary care providers on (a) diagnosing atrial fibrillation and (b) initiating and maintaining oral anticoagulation safely, to reduce the incidence of ischemic stroke? The comprehensive literature review not only provided extensive background information on atrial fibrillation and anticoagulation but also highlighted key references to first compare evidence to practice (analyze patient chart reviews) and then utilize these identified gaps to translate evidence into practice (create the anticoagulation toolkit). Furthermore, the PARIHS framework and RE-AIM model evaluated the ability to effectively facilitate the results from this research project into practice. Additionally, this capstone project met all five criteria of the EC as PIE model, concluding this was a successful Doctor of Nursing Practice capstone project. A future extension of this project suggests evaluation of patient outcomes with AF, predominantly stroke incidence, subsequent to implementation of this toolkit in the primary care setting.
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