CINCINNATI—New recommendations for some heart failure patients presenting to the emergency department could shorten hospital stays and provide similar, or perhaps better, outcomes, say emergency medicine researchers at the University of Cincinnati (UC) College of Medicine.
“The course of action to date has been to admit most heart failure patients to the hospital because it is difficult to judge who is well enough to go home,” says Sean Collins, MD, a UC Health emergency physician who co-authored with a team of other physicians and researchers an article published in the September 2009 edition of Critical Pathways in Cardiology.
The team examined the Society of Chest Pain Center’s recommendations for management of patients with heart failure.
Unlike a heart attack, which can be fatal within seconds to a few hours, heart failure is a weakening of the heart—a slower, degenerative disease state that keeps the heart from pushing blood forward to other vital organs, says Collins. Heart failure itself, he says, can be caused by a myriad of underlying factors such as the natural aging process, muscle deterioration from the aftermath of an actual heart attack and hypertension (high blood pressure), among others. Subsequently, patients with heart failure can experience complications that require prompt emergency care. For example, heart failure can cause loss of blood flow to the kidneys resulting in kidney failure.
But not everyone with heart failure needs to be admitted to the hospital because not all heart failure patients are high risk, Collins says. Some patients, especially those who present to hospitals with an emergency department observation unit such as UC Health University Hospital, could be monitored by emergency department physicians and released within 12-24 hours. That’s because, he says, some of the accompanying conditions can be stabilized with aggressive care in the emergency department. The new recommendations were written to help doctors decide who can get managed in this way, usually in an observation unit.
“An observation unit is managed 24 hours a day by emergency physicians and these patients are being seen around the clock. If they get better at 10 p.m., then they can go home at 10 p.m.,” he says.
According to Collins: “It is difficult to determine in the emergency department which patients are safe for discharge. Up to 5 percent of these patients admitted with heart failure will die in the hospital and 25 percent of those discharged from the hospital will be readmitted in the subsequent two months. Because of this high event rate and unpredictability regarding who is safe to discharge, over 80 percent of emergency department patients with heart failure are admitted to the hospital."
With heart failure largely a disease of the elderly, and with our population aging, the research team took a closer look at the recommendations to see if people really can be managed in this way, says Christopher Lindsell, PhD, an associate professor and director of research in emergency medicine who co-authored the new study.
”The moment a patient is admitted to the hospital, the costs go up, and it’s not just the money. Being admitted has more impact on patients’ everyday lives than getting to go home after a short stay in the emergency department, and admitting lower-risk patients means sicker patients may not get a bed,” says Lindsell.
The bottom line—both say—is that treatment in the emergency department for 12-24 hours is far less resource-intense than a two- to five-day hospital stay, which is currently the norm for low-risk patients.
“As the baby boomers are aging, we’re going to have a lot of people over 65 with heart failure,” says Collins, “and we see this as a paradigm shift in how we think about the management of acute heart failure in the inpatient setting.”