This is a patient with a history of diabetes, hypertension, hyperlipidemia, asthma, pulmonary embolism and obstructive sleep apnea. She presented to the emergency department complaining of chest tightness, dyspnea, palpitations and cough. Her blood pressure was 150/120 millimeters of mercury (mmHg) with a heart rate of 160 beats/minute. Room air oxygen saturation was 100%. Her physical exam was remarkable for obesity and a rapid, irregular rhythm. An electrocardiogram showed atrial fibrillation with a rapid ventricular rate and nonspecific repolarization changes. Her serum troponin level was normal. The health plan's determination of medical necessity is upheld. She presented with a new onset of atrial fibrillation (AF). She was hemodynamically stable and there was no evidence of myocardial ischemia or decompensated heart failure. In patients who present to the emergency department with acute AF, the safety of a lower level care or discharge to home with close follow-up has been well demonstrated.
Per the Milliman Care Guideline for Atrial Fibrillation (ORG: M-505) , indications for inpatient care include: hemodynamic instability, myocardial infarction or ischemia, altered mental status, syncope, heart failure, implantable cardioverter defibrillator discharges, Wolff Parkinson White syndrome, medication toxicity, severe electrolyte or acid base disturbance or other acute serious medical condition requiring inpatient care, need for initiation of antiarrhythmic drug therapy in a patient at high risk for adverse effects, persistent symptomatic tachycardia despite outpatient or observation level care or need for urgent or elective cardioversion that cannot be performed on an outpatient basis or during observation care. This patient met none of these criteria.