Patients With Acute Heart Failure in the Emergency Department: Do They All Need to Be Admitted?

doi:10.1016/j.cardfail.2012.10.014

Journal of Cardiac Failure

Volume 18, Issue 12, December 2012, Pages 900-903

https://doi.org/10.1016/j.cardfail.2012.10.014 Get rights and content

Abstract

Hospitalization for acute heart failure (AHF) is associated with a high rate of postdischarge mortality and readmissions, as well as high financial costs. Reducing 30-day readmissions after AHF hospitalization is a major national quality goal intended to both improve patient outcomes and reduce costs. Although the decision threshold for the vast majority of hospitalized AHF patients lies in the emergency department (ED), the role of the ED in reducing preventable admissions has largely been ignored. While admissions for AHF also originate from outpatient clinics, the greatest opportunity to reduce inpatient admissions lies with the cohort of patients who present to the ED with AHF. Safe discharge mandates interdisciplinary collaboration, close follow-up, careful scrutiny of psychosocial and socioeconomic factors, and a shared definition of risk stratification. Although additional research is needed, strategies for lower risk patients can and should be initiated to safely discharge AHF patients from the ED.

Section snippets

Which Patients Can Be Safely Discharged?

There are 3 primary exit pathways from the ED, all of which must occur in a timely fashion given the unceasing pressures of patients waiting to be seen: 1) inpatient admission; 2) observation status admission (outpatient status); and 3) discharge. Appropriate use of each pathway is in the best interests of patients and the health care system as a whole. At the same time, caution is warranted when considering discharge. Patients with HF are a complex and heterogeneous group, with significant

Conclusion

The decision to admit or discharge ED patients with AHF is made in the ED. Evidence to identify lower-risk patients already exists, combining clinical features with natruiretic peptides and other biomarkers (eg, troponin) along with medical comorbidities and social factors. Caution is warranted, however, given the complexity and heterogeneity of patients with HF and their high rate of postdischarge events. Even a small percentage decrease in admissions would result in a substantial absolute

Disclosures

Peter S. Pang, MD, currently or in the past 6 years, has been a consultant for Astellas, Bayer, EKR Therapeutics, J&J, The Medicines Company, Medtronic, Novartis, Otsuka, Palatin Technologies, PDL BioPharma, Pericor Therapeutics, SigmaTau, Solvay Pharmaceuticals, and Trevena and has received honoraria from Alere, Beckman-Coulter, BiogenIdec, Corthera, Ikaria, Nile Therapeutics, and Momentum Research and research support from Abbott, Merck, and PDL BioPharma. Peter is also supported by the

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Cited by (30)

Disposition of acute decompensated heart failure from the emergency department: An evidence-based review
2021, American Journal of Emergency Medicine
Acute heart failure (HF) exacerbation is a serious and common condition seen in the Emergency Department (ED) that has significant morbidity and mortality. There are multiple clinical decision tools that Emergency Physicians (EPs) can use to reach an appropriate evidence-based disposition for these patients.
This narrative review is an evidence-based discussion of clinical decision-making tools aimed to assist EPs risk stratify patients with AHF and determine disposition.
Risk stratification in patients with AHF exacerbation presenting to the ED is paramount in reaching an appropriate disposition decision. High risk features include hypotension, hypoxemia, elevated brain natriuretic peptide (BNP) and/or troponin, elevated creatinine, and hyponatremia. Patients who require continuous vasoactive infusions, respiratory support, or are initially treatment-resistant generally require intensive care unit admission. In most instances, new-onset AHF patients should be admitted for further evaluation. Other AHF patients in the ED can be risk stratified with the Ottawa HF Risk Score (OHFRS), the Multiple Estimation of Risk Based on Spanish Emergency Department Score (MEESSI), or the Emergency HF Mortality Risk Grade (EHFMRG). These tools take various factors into account such as mode of arrival to the ED, vital signs, laboratory values like troponin and pro-BNP, and clinical course. If used appropriately, these scores can predict patients at low risk for adverse outcomes.
This article discusses evidence-based disposition of patients in acute decompensated HF presenting to the ED. Knowledge of these factors and risk tools can assist emergency clinicians in determining appropriate disposition of patients with HF.
Management of Heart Failure in the Emergency Department Setting: An Evidence-Based Review of the Literature
2018, Journal of Emergency Medicine
Acute heart failure (AHF) is a common presentation to the emergency department (ED), with the potential to cause significant morbidity and mortality. It is important to tailor treatments to the appropriate type of heart failure.
This review provides an evidence-based summary of the current ED management of acute heart failure.
Heart failure can present along a spectrum, especially in acute exacerbation. Treatment should focus on the underlying disease process, with guidelines focusing primarily on blood pressure and hemodynamic status. Treatment of patients with mild AHF exacerbations often focuses on intravenous diuretics. Patients with AHF with flash pulmonary edema should receive nitroglycerin and noninvasive positive pressure ventilation, with consideration of an angiotensin-converting enzyme inhibitor, while monitoring for hypotension. Patients with hypotensive AHF should receive emergent specialty consultation and an initial fluid bolus of 250–500 mL, followed by initiation of inotropic agents with or without vasopressors. Dobutamine is the inotrope of choice in these patients, with norepinephrine recommended if blood pressure support is needed. If noninvasive positive pressure ventilation is required, providers should monitor closely for acute decompensation. Mechanical circulatory support devices may be considered as a bridge to further therapeutic intervention. High-output heart failure can be managed acutely with vasoconstricting agents, with focus on treating the underlying etiology. Disposition is not always straightforward, and several risk scores may assist in this decision.
AHF is a condition that requires rapid assessment and management. Understanding the appropriate management strategy can allow for more targeted treatment and improved outcomes.
Design and rationale of a randomized trial: Using short stay units instead of routine admission to improve patient centered health outcomes for acute heart failure patients (SSU-AHF)
2018, Contemporary Clinical Trials
Citation Excerpt :
Therefore, differentiating patients with AHF who require admission versus direct ED discharge or a brief period of observation, may help improve outcomes while reducing costs. Accurate and effective tools to identify patients with high-risk features of AHF, namely those with renal dysfunction, unstable vital signs, and elevated biomarkers such as natriuretic peptide and troponin have been developed [7–11]. Such patients often require hospitalization.
Nearly 85% of acute heart failure (AHF) patients who present to the emergency department (ED) with acute heart failure are hospitalized. Once hospitalized, within 30 days post-discharge, 27% of patients are re-hospitalized or die. Attempts to improve outcomes with novel therapies have all failed. The evidence for existing AHF therapies are poor: No currently used AHF treatment is known to improve long-term outcomes. ED treatment is largely the same today as 40 years ago. Admitting patients who could have avoided hospitalization may contribute to adverse outcomes. Hospitalization is not benign; patients enter a vulnerable phase post-discharge, at increased risk for morbidity and mortality. When hospitalization is able to be shortened or avoid completely, certain risks can be mitigated, including risk of medication errors, in-hospital falls, delirium, nosocomial infections, and other iatrogenic complications. Additionally, patients would prefer to be home, not hospitalized. Furthermore, hospitalization and re-hospitalization for AHF predominantly affects patients of lower socioeconomic status (SES). Avoiding hospitalization in patients who do not require admission may improve outcomes and quality of life, while reducing costs.
Short stay unit (SSU: <24 h, also referred to as an ‘observation unit’) management of AHF may be effective for lower risk patients. However, to date there have only been small studies or retrospective analyses on the SSU management for AHF patients. In addition, SSU management has been considered ‘cheating’ for hospitals trying to avoid 30-day readmission penalties, as SSUs or observation units do not count as an admission. However, more recent analyses demonstrate differential use of observation status has not led to decreases in re-admission, suggesting this concern may be misplaced. Thus, we propose a robust clinical effectiveness trial to demonstrate the effectiveness of this patient-centered strategy.
Acute Dyspnea and Decompensated Heart Failure
2018, Cardiology Clinics
Approach to Acute Heart Failure in the Emergency Department
2017, Progress in Cardiovascular Diseases
Citation Excerpt :
These tasks are often challenging to complete during a brief ED stay. Furthermore, given the reluctance to discharge lower-risk AHF patients from the ED, the use of observation medicine as a ‘bridge’ may be more clinically feasible and acceptable to ED physicians.3,93 For higher risk patients, hospitalization may offer benefit to improve symptoms, optimize volume status, and ensure initiation of guideline directed chronic medical therapy.
Acute heart failure (AHF) patients rarely present complaining of ‘acute heart failure.’ Rather, they initially present to the emergency department (ED) with a myriad of chief complaints, symptoms, and physical exam findings. Such heterogeneity prompts an initially broad differential diagnosis; securing the correct diagnosis can be challenging. Although AHF may be the ultimate diagnosis, the precipitant of decompensation must also be sought and addressed. For those AHF patients who present in respiratory or circulatory failure requiring immediate stabilization, treatment begins even while the diagnosis is uncertain.
The initial diagnostic workup consists of a thorough history and exam (with a particular focus on the cause of decompensation), an EKG, chest X-ray, laboratory testing, and point-of-care ultrasonography performed by a qualified clinician or technologist. We recommend initial treatment be guided by presenting phenotype. Hypertensive patients, particularly those in severe distress and markedly elevated blood pressure, should be treated aggressively with vasodilators, most commonly nitroglycerin. Normotensive patients generally require significant diuresis with intravenous loop diuretics. A small minority of patients present with hypotension or circulatory collapse. These patients are the most difficult to manage and require careful assessment of intra- and extra-vascular volume status. After stabilization, diagnosis, and management, most ED patients with AHF in the United States (US) are admitted. While this is understandable, it may be unnecessary. Ongoing research to improve diagnosis, initial treatment, risk stratification, and disposition may help ease the tremendous public health burden of AHF.
Cardiovascular Conditions in the Observation Unit: Beyond Chest Pain
2017, Emergency Medicine Clinics of North America
Citation Excerpt :
EDOUs have been established as excellent alternatives for patients who are not stable for immediate discharge from the ED but may not need greater than 24 hours of care. EDOUs provide a cost-effective alternative to admission that has been shown to offer savings, shorter stays, and reduced admissions.18–23 With proper patient selection and risk stratification, EDOU care can be a valuable tool in the management of patients with acute HF.

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PerspectivePatients With Acute Heart Failure in the Emergency Department: Do They All Need to Be Admitted?

Abstract

Section snippets

Which Patients Can Be Safely Discharged?

Conclusion

Disclosures

Am J Cardiol

Ann Emerg Med

J Am Coll Cardiol

Ann Emerg Med

J Am Coll Cardiol

J Am Coll Cardiol

Ann Emerg Med

Am J Emerg Med

J Am Coll Cardiol

Heart disease and stroke statistics—2010 update: a report from the American Heart Association

Circulation

Rehospitalizations among patients in the Medicare fee-for-service program

N Engl J Med

Perspective
Patients With Acute Heart Failure in the Emergency Department: Do They All Need to Be Admitted?