Editors: Peacock, W. Frank
Title: Short Stay Management of Heart Failure, 1st Edition
Copyright 2006 Lippincott Williams & Wilkins
> Table of Contents > 9 - Emergency Department and Observation Unit Discharge Criteria
Emergency Department and Observation Unit Discharge Criteria
Deborah B. Diercks
Heart failure (HF) causes substantial morbidity and mortality in the United States and is the most common principal discharge diagnosis in adults aged 65 years and older.1,2 and 3 Altogether, the costs for HF hospitalizations are approximately $14.7 billion per year.4 A substantial number of these patients present to the emergency department for the initial treatment of their acute decompensation. It has been suggested that 80% of all patients who present with acute decompensated heart failure (ADHF) are admitted to the hospital.5 Identifying patients who are suitable for discharge home or for admission to an observation unit (OU) may substantially reduce overall hospital costs. However, for emergency physicians, accurate disposition is a challenge and perhaps more daunting than the management of these patients.
Disposition decisions are often time-dependent and lack adequate time to assess response to treatment. This may result in inappropriate admissions and premature emergency department (ED) discharges, with resultant increased cost and morbidity, respectively.6,7 Although the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines on the management of HF suggest that patients with mild to moderate symptoms generally do not require admission, risk assessment based on symptoms is often difficult.5 To increase the number of patients discharged to home, effective treatment must be initiated in the ED as part of their ED management or an OU protocol. This early intervention and avoidance of hospital admission can result in significant cost savings, because 75% of costs arising from hospitalization for HF are incurred within the first 48 hours.4
Success of any protocol is dependent on accurate identification of patients suitable for an early discharge plan. Patients with a high probability of adverse outcome, such as those with evidence of acute cardiac ischemia, should be admitted to the hospital as in-patients. Blood pressure and heart rate are two of the most significant independent predictors of acute
As essential as the identification of appropriate patients for this rapid treatment protocol is, use of discharge criteria to result in a low rate of subsequent hospital readmission soon after discharge is also important. Unfortunately, there is a paucity of data addressing this issue in the ED, in-patient, and OU settings. Current methods of risk stratification have focused on identifying patients at risk for short- and long-term adverse events. Risk stratification is an ongoing process. It is dependent on clinical appearance, laboratory parameters, and response to acute therapies. Discharge to home should be considered from the perspective of an estimate of the acuity of the initial presentation of the patient, improvement in response to treatment, and risk of recidivism after discharge. It is suggested that certain clinical features should then alter the physician's initial acuity estimate and improvement in these parameters can identify patients suitable for discharge to home.
Consensus guidelines for discharge from the ED and OU have been developed.10 These guidelines are based on the presence of factors associated with increased risk for adverse events. Although the absence of these parameters does not ensure that a patient is ready for discharge, they are useful in identifying patients with persistent decompensated HF who would benefit from additional treatment. These discharge criteria can be divided into three categories: patient-centered measures, hemodynamic and clinical parameters, and laboratory results (Table 9-1).
It has been well established that patient-centered outcome measures, such as a change in dyspnea, can be used to assess therapeutic success and improvement in symptoms. Although subjective, the measurement of dyspnea on a seven-point or three-point scale is a validated outcome measure.11 In addition, the assessment of dyspnea has been shown to correlate with hemodynamic status in clinical trials. However, no study has evaluated this as an endpoint in an ED or OU, although it continues to be assessed in informal manners.11 Another patient-centered measure that should be present at the time of discharge is the lack of ongoing chest pain. It has been reported that acute coronary syndrome (ACS) is a trigger for up to 25% of HF decompensation. Therefore, patients should be pain free or have undergone an evaluation for ACS prior to discharge.12 Finally, the patient should be able to ambulate without an increase in dyspnea from baseline. Although no trial has assessed this measure in an OU setting, it effectively is an inexpensive 6-minute exercise test. The distance that
TABLE 9-1 Discharge Criteria
Hemodynamic and clinical parameters can also be used as part of the data to assess suitability for discharge. These comprise measures of perfusion, volume status, and oxygenation based physical examination findings and automated measures. SBP is a useful predictor of adverse events at the time of presentation and discharge.15 In the initial presentation of patients with decompensated HF, a hypertensive response is adaptive; however, persistent elevation of SBP can correlate with increased risk of worsening renal function. This deterioration of renal function clearly correlates with morbidity and mortality; therefore, adjustment of medications to prevent hypertension is essential prior to discharge. Although the ideal blood pressure at the time of hospital discharge is not clearly elucidated, patients should at least have an SBP less than 160 mm Hg.15 In addition, as medications are titrated patients must be able to ambulate without symptoms of dizziness; therefore, patients should have an SBP greater than 90 mm Hg.10
Clinical findings can also be used to assess adequacy of acute interventions. These include a combination of changes in physical examination findings and easily obtained values, such as pulse oximetry, weight, and urine output. Of all the clinical examination findings, the presence of an S3 is most suggestive of acute decompensation.16 Serial examinations that can document the resolution of an S3 can be used as a discharge criteria.16 This physical examination finding, like an improvement in jugular venous distention, is dependent on physical attributes of the patient and careful physical examination assessment by the physician. Another criterion noted as part of the evaluation is oxygen saturation. Patients should have an oxygen saturation greater than 90%.10 No data exist to support this value; however, it is reasonable to discharge only patients who are able to maintain their oxygen saturation. Transient nighttime drops in oxygen saturation are common because HF is associated with an increased prevalence of obstructive sleep apnea. Therefore, pulse oximetry as a discharge criterion should be assessed when the patient is awake.
Urine output assessment is another parameter that can be used as a surrogate to assess treatment efficacy. Although there are no studies that compare the amount of urine output with outcomes, intuitively this makes sense. Clinically, 1 liter (L) appears to be a significant amount. Closely linked to urine output is a decline in patient weight.10 Dry weight is often one of the only baseline parameters that we know in the ED. Theoretically, a decline in the patient's weight can represent a resolution of the acute progression of the disease process; however, overshooting this parameter can lead to hypotension, hypoperfusion, and worsening renal function. Although not supported by clinical trials, it is reasonable to suggest that a patient's weight should be declining at the time of discharge; however, additional assessment may be warranted in patients who are below their dry weight at the time of discharge.
Improvement in laboratory results may be used to assess patients at the time of discharge. Studies have shown that a decline in B-type natriuretic peptide (BNP) levels is associated with improved morbidity and decreased hospital readmission rate.17,18 and 19 However, no study has looked at the change in BNP levels in the less than 23-hour timeframe. It makes intuitive sense that a patient's BNP should be declining at the time of discharge assessment, although the exact amount of decline is unknown. Elevated troponin levels have been shown to be predictive of long-term prognosis in HF patients.20 Patients with severe HF may have chronically elevated levels. However, a rise in troponin levels during an OU stay should provoke concern and may reflect inadequacy of treatment or the presence of ACS. In addition, patients with an elevated initial troponin level have been shown to be more likely to stay in the hospital greater than 24 hours and have a high rate of 30-day hospital readmission.21 Therefore, patients with an elevated initial troponin level are probably not suitable for an early discharge strategy.
Traditional chemistry laboratory tests that are routinely assessed daily in patients with decompensated HF can also be used in the assessment of a patient at the time of discharge. A sodium level of less than 136 mEq/L and a serum blood urea nitrogen (BUN) greater than 43 mg/dL have been shown to correlate with 1-year and acute mortality, respectively.8,22 Therefore, improvement in the BUN and serum creatinine in patients with abnormal values is a potential marker of treatment success and may be useful in determining disposition.23 At this point, there are no trials that have used these values in this capacity. Recently, a significant amount of attention has been placed on the significance of worsening serum creatinine in the setting of treatment for decompensated HF. A recent study has shown that an increase in creatinine level of greater than 0.3 mg/dL from hospital admission correlates with greater rates of in-hospital death, increased complications, and longer length of stay. The presence of worsening renal insufficiency as defined by a creatinine change greater than 0.3 mg/dL from prior values is concerning, and therefore patients warrant further treatment until the creatinine improves or stabilizes.24
Independent of the clinical presentation, the success of early discharge is dependent on adequate outpatient follow-up and appropriate medication adjustment at the time of discharge. The initial improvements gained in the ED or OU can be quickly negated if the patient is discharged without a suitable outpatient management plan. Key components include close follow-up to ensure adequate medication adjustment, dietary education, and a management plan (Table 9-2). An important component of outpatient HF disease management includes25,26 a cohesive management plan, which has been shown to result in a 25% to 75% reduction in hospitalization.27,28
TABLE 9-2 Outpatient Key Components
Optimizing the medical regimen is another complex portion of the disposition process, because it requires coordination among many providers, including the treating ED physician, OU treating physician, consultants, and the outpatient provider. Although beyond the scope of this chapter, medication considerations should include the titration of loop diuretic, spironolactone, angiotensin-converting enzyme inhibitor, beta-blockers, and possibly nitrates.25,26
It should also be noted that every patient will not fit every criterion and that every recommendation must be interpreted with the patient's
1. Massie BM, Shah NB. Evolving trends in the epidemiologic factors of heart failure: rationale for preventive strategies and comprehensive disease management. Am Heart J 1997;133:703 712.
2. Rich MW. Epidemiology, pathophysiology, and etiology of congestive heart failure in older adults. J Am Geriatr Soc 1997;45:968 974.
3. Haldeman GA, Croft JB, Giles WH, et al. Hospitalization of patients with heart failure: National Hospital Discharge Survey, 1985 to 1995. Am Heart J 1999;137:352 360.
4. American Heart Association, American Stroke Association. Heart disease and stroke statistics 2004 update. Available at http://www.americanheart.org/downloadable/heart/ 1072969766940HSStats2004Update.pdf (accessed May 15, 2005).
5. Hunt SA, Baker DW, Chin MH, et al. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult. J Am Coll Cardiol 2001;38:2101 2113.
6. Kosecoff J, Kahn KL, Rogers WH, et al. Prospective payment system and the impairment at discharge: the quicker and sicker story revisited. JAMA 1990;264:1980 1983.
7. Peacock WF IV, Remer ER, Aponte J, et al. Effective observation unit treatment of decompensated heart failure. Congest Heart Fail 2002;8:68 73.
8. Fonarow GC, Adams KF Jr, Abraham WT, et al. Risk stratification for in-hospital mortality in acutely decompensated heart failure: classification and regression tree analysis. JAMA 2005;293:572 580.
9. Peacock WF, Emerman CL, on behalf of the PROACTION Study Group. Safety and efficacy of nesiritide in the treatment of decompensated heart failure in observation patients [abstract 1027-89]. J Am Coll Cardiol 2003;41[Suppl A]:336A.
10. Cleveland Clinic. Management of acute decompensated heart failure in the emergency department. Available at http://www.clevelandclinicmeded.com/hfed/disch_guide.htm (accessed June 14, 2004).
11. Teerlink JR. Dyspnea as an end point in clinical trials of therapies for acute decompensated heart failure [review]. Am Heart J 2003;145[Suppl 2]:S26 S33.
12. Khand AU, Gemmell I, Rankin AC, Cleland JG. Clinical events leading to the progression of heart failure: insights from a national database of hospital discharges. Eur Heart J 2001;22:153 164.
13. Rostagno C, Olivo G, Comeglio M, et al. Prognostic value of 6-minute walk corridor test in patients with mild to moderate heart failure: comparison with other methods of functional evaluation. Eur J Heart Fail 2003;5:247 252.
14. Luca C, Johnson W, Hamilton MA, et al. Freedom from congestion predicts good survival despite previous class IV symptoms of heart failure. Am Heart J 2000;140:840 847.
15. Forman DE, Butler J, Wang Y, et al. Incidence, predictors at admission, and impact of worsening renal function among patients hospitalized with heart failure. J Am Coll Cardiol 2004;43:61 67.
16. Marantz PR, Kaplan MC, Alderman MH. Clinical diagnosis of congestive heart failure in patients with acute dyspnea. Chest 1990;97:776 781.
17. Cheng V, Kazanagra R, Garcia A, et al. A rapid bedside test for B-type peptide predicts treatment outcomes in patients admitted for decompensated heart failure: a pilot study. J Am Coll Cardiol 2001;37:386 391.
18. Knebel F, Schimke I, Pliet K, et al. NT-ProBNP in acute heart failure: correlation with invasively measured hemodynamic parameters during recompensation. J Card Fail 2005;11[5 Suppl]:S38 41.
19. Kazanegra R, Cheng V, Garcia A, et al. A rapid test for B-type natriuretic peptide correlates with falling wedge pressures in patients treated for decompensated heart failure: a pilot study. J Card Fail 2001;7:21 29.
20. Potluri S, Ventura HO, Mulumudi M, Mehra MR. Cardiac troponin levels in heart failure. Cardiol Rev 2004;12:21 25.
21. Diercks DB, Peacock WF, Kirk JD, Weber JE. Emergency department heart failure patients: identification of an observational unit appropriate cohort. J Card Fail 2004(abst).
22. Felker GM, Leimberger JD, Califf RM, et al. Risk stratification after hospitalization for decompensated heart failure. J Card Fail 2004;10:460 466.
23. Lee DS, Austin PC, Rouleau JL, et al. Predicting mortality among patients hospitalized for heart failure: derivation and validation of a clinical model. JAMA 2003;290:2581 2587.
24. Forman DE, Butler J, Wang Y, et al. Incidence, predictors at admission, and impact of worsening renal function among patients hospitalized with heart failure. J Am Coll Cardiol 2004;43:61 67.
25. Nohria A, Lewis E, Stevenson LW. Medical management of heart failure. JAMA 2002;287:628 640.
26. Peacock WF 4th. Rapid optimization: strategies for optimal care of decompensated congestive heart failure patients in the emergency department. Rev Cardiovasc Med 2002;3[Suppl4]:S41 S48.
27. Rich MW, Beckham V, Wittenberg C, et al. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. N Engl J Med 1995;333:1190 1195.
28. Hanumanthu S, Butler J, Chomsky D, et al. Effect of a heart failure program on hospitalization frequency and exercise tolerance. Circulation 1997;96:2842 2848.