1 - Heart Failure in the Observation Unit | Short Stay Management of Heart Failure

Editors: Peacock, W. Frank

Title: Short Stay Management of Heart Failure, 1st Edition

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Heart Failure in the Observation Unit

W. F. Peacock

Why Heart Failure?

Plain and simple, heart failure is the number one disease in our country. This is a poorly recognized fact that results from the confluence of society's excesses with the medical community's success in staving off the inevitable consequences of sedentary overconsumption and self-indulgence. Because we live at a time and in a place where myocardial infarction is not a uniformly fatal event, where obesity exists in epidemic proportions, where the coronary artery stent and coronary artery bypass graft (CABG) are part of the routine layperson's coffee table vernacular, and where hypertensive and diabetic individuals routinely live for scores of years after their diagnosis, we have created an entire subpopulation of Americans who survive with serious compromise to their cardiovascular function.

As recently as 30 years ago, these patients simply died of complications from their diseases. Today they commonly survive, only to reenter the medical establishment in later years with the development of heart failure. Thus, heart failure has become the disease of the 21st century. It is also the chronic ailment that steals the quality of life from the golden years of America's fastest growing demographic segment: the elderly. No other single disease causes more hospitalizations, and few other pathologies can as effectively maim and suffocate its victims, as heart failure is routinely manifested.

Unfortunately, in its early stages, heart failure is relatively asymptomatic and passes unnoticed until the patient presents with symptoms of progressive shortness of breath. Although the patient may give a history of a relatively new onset of dysfunction, in reality the underlying syndrome has been present chronically, sometimes for years. It is the symptom of suffocation that drives heart failure patients to the emergency department. As has been shown in data from the ADHERE registry, more than 90% of heart failure patients present acutely with shortness of breath. It is ultimately dyspnea that results in their hospitalization and it is breathlessness that is

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the limiting parameter preventing their discharge home. Consequently, the relief of shortness of breath becomes the driving event determining both the length of hospitalization required and the quality of life in the heart failure patient.

Heart failure has been termed the merry-go-round disease. This is because of the well-known cycle of worsening symptoms, hospital admission, discharge home, followed by worsening symptoms and repeat of the same cycle. If only it were so. The unfortunate reality is that the long-term course of heart failure more resembles a roller coaster than a merry-go-round. On a merry-go-round, the cycle is repeated and the patient returns to where he or she started. However, on a roller coaster, the highest level of function is the first day, and it is all downhill from there. In heart failure, the patient is initially functional, worsens, and is hospitalized and is discharged, usually not in as good a condition as when first stricken, only to repeat this cycle. Therefore, what seems like a repeating cycle is actually a downward spiral ending inevitably, usually within 5 years, with the patient's death.

This roller coaster ride is not good for the patient. Constant repeat visits and the expensive polypharmacy that defines contemporary heart failure management serve to steal quality of life and robs the patient of his or her life savings. It is not just the patient who is financially burdened. Heart failure costs the medical establishment huge sums of money. The Center for Medicare and Medicaid Studies spends more on heart failure care than on any other single disease.

Solutions to this problem, both from the patient's point of view and from the perspective of the health care provider, are sorely needed. Business as usual has been a dismal failure for the treatment of heart failure. The number of heart failure hospitalizations has dramatically risen over the last 30 years and will surpass 1 million in 2005. When we consider that the most common heart failure patient in the ADHERE registry is a 75-year-old white woman, the future is daunting. All demographic projections of an aging United States suggest that the number of people stricken with heart failure can only markedly increase.

New and creative solutions must be implemented. This book represents the first of its kind to focus on acute decompensated heart failure treatment without conventional hospitalization. Our goals are to improve the patient's quality of life by avoiding hospitalizations and to do so in a financially effective manner.

Having to Go First is Harder than it Looks

I have often wondered when humans were first faced with the necessity of digging a hole, how did they come to decide to make a shovel? It is a pretty rudimentary object, a relatively small piece of metal plate with a curved shape, a point at one end, and a place where the handle goes. It was most certainly not invented by a rocket scientist. But what if you had

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never seen one? What if metal had not even been invented? Would the shovel be the first tool you would spend your time making? After all, remember, you just needed a hole. So it is likely that the first shovel probably looked more like a stick. And that is the conundrum of going first. The final solution to any given problem will likely not resemble the answer to the challenge that was the original objective, and so it is with heart failure. This is the first book to tackle the problem of digging out of the hole that we currently know as heart failure. We hope it will not be the last. We hope, too, that this represents the first in a long chain of refinements toward the goal of meeting the challenge of the number one disease in America.

Clarification of Terms

Throughout this manuscript little attempt has been made to standardize terms. This represents the current state of the literature, as much as the billing structure that drives the medical establishment. Whether the unit is called an emergency department observation unit, a short stay unit, or a rapid diagnostic and treatment unit is unimportant. Whether it is managed by emergency physicians, internists, cardiologists, or nurse practitioners is superfluous. Finally, whether it is in a specialized location with dedicated beds and equipment or a virtual unit with no defined geography, the desired outcome remains the same. The common goal, and the objective of this book, is that all heart failure patients receive early diagnosis and effective treatment that allows a rapid discharge that does not require a revisit within 30 days.

Thus, in reality, standardization of terms is irrelevant. The intent of this book is to outline strategies for the early diagnosis and treatment of the acutely decompensated heart failure patient in a short stay unit. What a short stay unit is has intentionally been left vague. The geography of where the care occurs or the medical background of the practitioners has little relevance. What is important is a common dedication to improving outcomes for patients presenting with acutely decompensated heart failure.

On the Shoulders of Giants

No introduction to this book could possibly be complete without the appropriate thanks to those who have made this book possible. For this, we stand on the shoulders of two giants. It was in Michigan, in the last decade of the 20th century when Dr. Raymond Bahr, a forward-thinking cardiologist, brought to fruition his idea of a new society dedicated to the care of the chest pain patient. Many years later, this ultimately came to be what we now know as the Society for Chest Pain. Interestingly, like the man who just needed to dig a hole, there was no way for Ray to know that, many years later, the society he formed in the basement of a Detroit hotel

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would become the standard bearer for heart failure and serve to spawn an entirely different perspective of care for entire groups of patients. Much thanks must go to Ray for his ability to think outside the box.

Second, due thanks must be given to Lou Graff who, in the same decade, published the first-ever book on rapid diagnosis and treatment units. Titled Observation Medicine, this book became the standard bearer and served as the how to manual for many subsequent hospitals to organize their observation units. Without the confluence of chest pain units, supported and advanced by Ray Bahr, and the concept of observation medicine, defined and promoted by Lou Graff, the necessary pieces to care for heart failure patients in a short stay unit would not exist today.

It is our hope that this book will perform in a manner similar to its predecessors, in the fashion of assisting practitioners in the search for new ways to improve outcomes for their patients' quality of life and their hospital partners.