Evaluation of an adaptive, rule-based dosing algorithm to maintain therapeutic anticoagulation during atrial fibrillation ablation
Cerebral thromboembolism during atrial fibrillation (AF) ablation is an infrequent (0.17%) complication in part owing to strict adherence to intraprocedural anticoagulation. Failure to maintain therapeutic anticoagulation can lead to an increase in events, including silent cerebral ischemia. To eval...
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| Published in: | Cardiovascular digital health journal Vol. 4; no. 6; pp. 173 - 182 |
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| Main Authors: | , , , , , , , , |
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01-12-2023
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| Abstract | Cerebral thromboembolism during atrial fibrillation (AF) ablation is an infrequent (0.17%) complication in part owing to strict adherence to intraprocedural anticoagulation. Failure to maintain therapeutic anticoagulation can lead to an increase in events, including silent cerebral ischemia.
To evaluate a computerized, clinical decision support system (CDSS) to dose intraprocedural anticoagulation and determine if it leads to improved intraprocedural anticoagulation outcomes during AF ablation.
The Digital Intern dosing algorithm is an adaptive, rule-based CDSS for heparin dosing. The initial dose is calculated from the patient's weight, baseline activated clotting time (ACT), and outpatient anticoagulant. Subsequent recommendations adapt based on individual patient ACT changes. Outcomes from 50 cases prior to algorithm introduction were compared to 139 cases using the algorithm.
Procedures using the dosing algorithm reached goal ACT (over 300 seconds) faster (17.6 ± 11.1 minutes vs 33.3 ± 23.6 minutes pre-algorithm,
< .001). ACTs fell below goal while in the LA (odds ratio 0.20 [0.10-0.39],
< .001) and rose above 400 seconds less frequently (odds ratio 0.21 [0.07-0.59],
= .003). System Usability Scale scores were excellent (96 ± 5, n = 7, score >80.3 excellent). Preprocedure anticoagulant, weight, baseline ACT, age, sex, and renal function were potential predictors of heparin dose to achieve ACT >300 seconds and final infusion rate.
A heparin dosing CDSS based on rules and adaptation to individual patient response improved maintenance of therapeutic ACT during AF ablation and was rated highly by nurses for usability. |
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| AbstractList | BackgroundCerebral thromboembolism during atrial fibrillation (AF) ablation is an infrequent (0.17%) complication in part owing to strict adherence to intraprocedural anticoagulation. Failure to maintain therapeutic anticoagulation can lead to an increase in events, including silent cerebral ischemia.ObjectiveTo evaluate a computerized, clinical decision support system (CDSS) to dose intraprocedural anticoagulation and determine if it leads to improved intraprocedural anticoagulation outcomes during AF ablation.MethodsThe Digital Intern dosing algorithm is an adaptive, rule-based CDSS for heparin dosing. The initial dose is calculated from the patient's weight, baseline activated clotting time (ACT), and outpatient anticoagulant. Subsequent recommendations adapt based on individual patient ACT changes. Outcomes from 50 cases prior to algorithm introduction were compared to 139 cases using the algorithm.ResultsProcedures using the dosing algorithm reached goal ACT (over 300 seconds) faster (17.6 ± 11.1 minutes vs 33.3 ± 23.6 minutes pre-algorithm, P < .001). ACTs fell below goal while in the LA (odds ratio 0.20 [0.10-0.39], P < .001) and rose above 400 seconds less frequently (odds ratio 0.21 [0.07-0.59], P = .003). System Usability Scale scores were excellent (96 ± 5, n = 7, score >80.3 excellent). Preprocedure anticoagulant, weight, baseline ACT, age, sex, and renal function were potential predictors of heparin dose to achieve ACT >300 seconds and final infusion rate.ConclusionA heparin dosing CDSS based on rules and adaptation to individual patient response improved maintenance of therapeutic ACT during AF ablation and was rated highly by nurses for usability. Cerebral thromboembolism during atrial fibrillation (AF) ablation is an infrequent (0.17%) complication in part owing to strict adherence to intraprocedural anticoagulation. Failure to maintain therapeutic anticoagulation can lead to an increase in events, including silent cerebral ischemia. To evaluate a computerized, clinical decision support system (CDSS) to dose intraprocedural anticoagulation and determine if it leads to improved intraprocedural anticoagulation outcomes during AF ablation. The Digital Intern dosing algorithm is an adaptive, rule-based CDSS for heparin dosing. The initial dose is calculated from the patient's weight, baseline activated clotting time (ACT), and outpatient anticoagulant. Subsequent recommendations adapt based on individual patient ACT changes. Outcomes from 50 cases prior to algorithm introduction were compared to 139 cases using the algorithm. Procedures using the dosing algorithm reached goal ACT (over 300 seconds) faster (17.6 ± 11.1 minutes vs 33.3 ± 23.6 minutes pre-algorithm, < .001). ACTs fell below goal while in the LA (odds ratio 0.20 [0.10-0.39], < .001) and rose above 400 seconds less frequently (odds ratio 0.21 [0.07-0.59], = .003). System Usability Scale scores were excellent (96 ± 5, n = 7, score >80.3 excellent). Preprocedure anticoagulant, weight, baseline ACT, age, sex, and renal function were potential predictors of heparin dose to achieve ACT >300 seconds and final infusion rate. A heparin dosing CDSS based on rules and adaptation to individual patient response improved maintenance of therapeutic ACT during AF ablation and was rated highly by nurses for usability. |
| Author | Kalscheur, Matthew M Kipp, Ryan T Mahnke, Marcus Martini, Matthew R Wright, Jennifer M Osman, Fauzia Fleeman, Blake E Medow, Joshua E Modaff, Daniel S |
| Author_xml | – sequence: 1 givenname: Matthew M surname: Kalscheur fullname: Kalscheur, Matthew M organization: Division of Cardiovascular Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin – sequence: 2 givenname: Matthew R surname: Martini fullname: Martini, Matthew R organization: Division of Cardiovascular Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin – sequence: 3 givenname: Marcus surname: Mahnke fullname: Mahnke, Marcus organization: Integrated Vital Medical Dynamics, LLC, Madison, Wisconsin – sequence: 4 givenname: Fauzia surname: Osman fullname: Osman, Fauzia organization: Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin – sequence: 5 givenname: Daniel S surname: Modaff fullname: Modaff, Daniel S organization: Division of Cardiovascular Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin – sequence: 6 givenname: Blake E surname: Fleeman fullname: Fleeman, Blake E organization: Division of Cardiovascular Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin – sequence: 7 givenname: Ryan T surname: Kipp fullname: Kipp, Ryan T organization: Division of Cardiovascular Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin – sequence: 8 givenname: Jennifer M surname: Wright fullname: Wright, Jennifer M organization: Division of Cardiovascular Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin – sequence: 9 givenname: Joshua E surname: Medow fullname: Medow, Joshua E organization: Departments of Neurosurgery, Neurology, and Biomedical Engineering, Medical College of Wisconsin, Milwaukee, Wisconsin |
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| Cites_doi | 10.1016/j.hrthm.2017.05.012 10.1161/CIRCULATIONAHA.117.033326 10.1002/clc.22944 10.1007/s10840-008-9270-x 10.1007/s00380-018-1294-2 10.1111/j.1540-8167.2005.40686.x 10.1177/1074248421998492 10.1111/jce.13314 10.1111/trf.14637 10.1038/s41746-020-0221-y 10.1161/CIRCULATIONAHA.109.921320 10.1161/CIR.0000000000000913 10.1111/1475-6773.13907 10.7326/M19-0875 10.1111/jce.14892 10.1016/j.hrthm.2014.03.003 10.3390/jcm9020350 10.1016/j.jacc.2004.01.031 10.1016/j.jacc.2023.03.418 10.1111/jce.12975 10.1197/jamia.M3092 10.1007/s10840-019-00579-y 10.1136/bmj.38398.500764.8F 10.1002/clc.23120 10.1161/CIRCRESAHA.120.316340 10.1093/eurheartj/ehy176 |
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| Keywords | Clinical decision support system Quality improvement Anticoagulation Atrial fibrillation Catheter ablation Implementation |
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