Stuck between a rock and a hard place for an alternative ED disposition
Congestive heart failure (CHF) results in over one million hospital admissions a year, and is the second most common reason for admission to a hospital from the Emergency Department (ED). In current practice, only 15-20% of patients with ED diagnosis of heart failure are discharged home from the ED. At an average cost of $23,077 per heart failure admission,  even a small percentage decrease in number of admissions would save millions in health care cost.
This review will explore why such a high proportion of patients presenting to emergency departments with an acute decompensation or a new diagnosis of heart failure are hospitalized. Consideration will be given to alternative methods of management. To begin, current guidelines and what factors contribute to this hospitalization “epidemic” will be outlined. Potential solutions to this problem, including observation units and the development of a risk stratification model, will then be considered.
Neither of the current guidelines from the Society of Chest Pain Centers (SCPC) and the American Heart Failure Association (AHFA) gives a blanket recommendation of admission for all patients with acute decompensated heart failure (ADHF). The SCPC recommends that patients demonstrating renal dysfunction, low serum sodium, low systolic blood pressure (SBP), new ischemic changes on ECG, or positive cardiac troponin levels be admitted for further evaluation and treatment. Those with BNP levels >1000 or borderline-low SPB of 100-120mmHg should have admission considered. However, the guidelines also suggest that certain HF patients can be managed in observation units, although characteristics of this select population are not well outlined in the guidelines.
The 2010 AHFA recommendations for hospitalization of ADHF patients are similar to those of the SCPC. However, patients with “previously undiagnosed heart failure with signs and symptoms of systemic or pulmonary congestion” do not automatically fall into this category. In this group, hospitalization should be considered on a case-by-case basis. Despite this, ED physicians routinely admit all newly diagnosed heart failure patients (or all acutely decompensated patients). Why the knee jerk reaction to hospitalize?
A variety of factors contribute to the ED practitioner’s low threshold for admission. Physicians, cognizant of the long-term morbidity and mortality of the disease, tend to overestimate short-term probability of death or severe complications for patients with acute CHF. Although studies have identified multiple predictive factors for low risk adverse events (and thus suitable for observation units), including SBP>160 and initial normal troponin, there is currently no well-established risk stratification for such patients presenting the ED. A retrospective chart review at an urban county hospital provides a second reason for high admission rates. The study reported that 61% of patients who were discharged from the ED with a diagnosis of CHF failed outpatient therapy within 90 days of discharge as defined by: a return ED visit for CHF, admission to the hospital for CHF, or death.  While only a single center study, the percentage is still drastically higher than the 25% all-cause 30-day readmission rates of heart failure patients discharged from inpatient. Thus, it is of little surprise that the path of a CHF patient arriving at an emergency room almost inevitably leads directly to the wards.
A patient who is receiving a new diagnosis of heart failure in the ED setting will likely be acutely decompensated, but such de novo patients make up a minority (21%) of all ADHF patients. Almost all decompensated patients require intravenous diuretics, but rarely demonstrate a need for time sensitive interventions or therapies, such as intravenous ionotropes. For those that do require such intensive measures, there will be no question about the appropriateness of an admission. However, for most ADHF patients, symptoms resolve within 24 hours.  But 24 hours is an unacceptable ED length of stay, and therefore such patients often gain a hospital admission. It is at this group of patients, those requiring a mild to moderate level of escalated care and whose ER disposition is not so clear cut, that alternative solutions are aimed. Suggestions addressing this problem include observation units and development of a risk stratification model.
Observation units (OU) have been addressed in the literature for over a decade, but recently have become a more prevalent topic given their potential to cut health care costs. They seem to be a near ideal solution for those patients who require short term interventions. An OU saves hospital costs while allowing for routine diagnostic testing to take place, medication regimens to be optimized, education provided and early follow up arranged for patients without actually being hospitalized. These units are similar to those already established for low risk chest pain in many institutions. However, no guidelines exist outlining an ADHF patient selection processes or risk stratification details. Nor have randomized clinical trials been conducted to determine how an observation unit compares to current practice in managing ADHF. 11 12
An observation unit will also be able to provide telemetry monitoring, if so desired. In 2004, telemetry was considered a practice standard by the American Heart Association (AHA) for all patients presenting with acute heart failure. This is due to the risk of ventricular and atrial arrhythmias which may be brought on by ADHF.  A European study suggests that telemetry may not be needed, finding that medical decisions are rarely guided by the telemetry ﬁndings. The authors report that the main telemetry effect seems to be that of reassuring physicians and patients. Most recently, the 2013 AHA Guideline for the Management of Heart Failure makes no mention of telemetry or electrocardiographic monitoring during admission except for 12 lead ECG.
A second option to manage ADHF without hospitalization is that of an infusion room, an open access site for patients to receive IV furosemide infusions. A pilot prospective nonrandomized observational cohort study in Miami reported no documented adverse reactions for patients receiving treatment and an avoidance of 115 ED visits. However the study was not designed nor adequately powered to evaluate differences in mortality of those using the infusion room and who did not. 
While observation units have been predicted to reduce the financial burden of hospitalizations by 50%, it is unlikely the number of patients directly discharged from Emergency Departments will change until a better way of assessing a patient’s risk is developed. One such possibility is to create a risk assessment score which augments the physician’s knowledge for making disposition decisions; an idea analogous to the PORT scoring system.
In a retrospective cohort study, Auble et al, derived a clinical prediction rule for low-risk acute heart failure aimed at identifying those patients who are at low risk for inpatient death or serious medical complication. A secondary aim was to examine the rates of death and readmission within 30 days of the initial hospitalization for patients identiﬁed by the rule as low risk. Using 21 variables, their prediction rule classified 17.2% (5,758 of 33,533) of patients hospitalized for heart failure as at low risk of short term medical outcomes. Of the 17%, 19 (0.3%) died in hospital and 59 (1.0%) survived to hospital discharge after experiencing a serious medical complication (either a life-threatening clinical condition or received a lifesaving inpatient treatment). Secondary outcomes were also significantly lower than those of high risk patients. This model was validated in both retrospective and prospective cohort trials, though limited by sample size and population limitations.   While evaluation in a cohort of ADHF patients including those treated as outpatients from the ED is still needed, the prediction rule is an important step towards eventually providing emergency physicians a tool of objective evidence to include in their clinical assessment of patients.
Until a clinical prediction rule can be validated to assist in determining low and high risk ADHF patients, it is unlikely that rates of direct discharge from EDs will change. However, alternative methods of managing these patients with observation suites and infusion room may offer a means of offsetting the high rate of hospital admissions and consequent health care expenditure.
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