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Emergency Department and Observation Unit Discharge Criteria

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Short Stay Management of Acute Heart Failure

Part of the book series: Contemporary Cardiology ((CONCARD))

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Abstract

Appropriate discharge and disposition from the emergency department and observation unit results in decreased recidivism and improved patient outcomes. Response to therapy as measured by improved symptoms or urinary output may be utilized to guide this decision. In addition, laboratory values can also be helpful in the disposition decision-making process. As heart failure is a chronic disease, a patient’s baseline status must be considered in all disposition decisions. This chapter will review how patient-centered measures of dyspnea, changes in laboratory parameters, and physical exam findings can be utilized in the decision to discharge heart failure patients from an observation unit or the emergency department.

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References

  1. Ahmed A, Allman RM, Fonarow GC, et al. Incident heart failure hospitalization and subsequent mortality in chronic heart failure: a propensity-matched study. J Card Fail. 2008;14:211–8.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Rosamond W, Flegal K, Furie K, et al. Heart disease and stroke statistics–2008 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2008;117:e25–146.

    Article  PubMed  Google Scholar 

  3. Schrock JW, Emerman CL. Observation unit management of acute decompensated heart failure. Heart Fail Clin. 2009;5:85–100.

    Article  PubMed  Google Scholar 

  4. Collins SP, Pang PS, Lindsell CJ, et al. International variations in the clinical, diagnostic, and treatment characteristics of emergency department patients with acute heart failure syndromes. Eur J Heart Fail. 2010;12:1253–60.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Lee DS, Schull MJ, Alter DA, et al. Early deaths in patients with heart failure discharged from the emergency department: a population-based analysis. Circ Heart Fail. 2010;3:228–35.

    Article  PubMed  Google Scholar 

  6. Kosecoff J, Kahn KL, Rogers WH, et al. Prospective payment system and impairment at discharge. The ‘quicker-and-sicker’ story revisited. JAMA. 1990;264:1980–3.

    Article  PubMed  CAS  Google Scholar 

  7. Hunt SA, Abraham WT, Chin MH, et al. 2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. J Am Coll Cardiol. 2009;53:e1–90.

    Article  PubMed  Google Scholar 

  8. Collins SP, Schauer DP, Gupta A, Brunner H, Storrow AB, Eckman MH. Cost-effectiveness analysis of ED decision making in patients with non-high-risk heart failure. Am J Emerg Med. 2009;27:293–302.

    Article  PubMed  Google Scholar 

  9. Fonarow GC, Adams Jr KF, Abraham WT, Yancy CW, Boscardin WJ. Risk stratification for in-hospital mortality in acutely decompensated heart failure: classification and regression tree analysis. JAMA. 2005;293:572–80.

    Article  PubMed  CAS  Google Scholar 

  10. Peacock WF, Fonarow GC, Ander DS, et al. Society of Chest Pain Centers recommendations for the evaluation and management of the observation stay acute heart failure patient—parts 1–6. Acute Card Care. 2009;11:3–42.

    Article  PubMed  Google Scholar 

  11. Diercks DB, Peacock WF, Kirk JD, Weber JE. ED patients with heart failure: identification of an observational unit-appropriate cohort. Am J Emerg Med. 2006;24:319–24.

    Article  PubMed  Google Scholar 

  12. Burkhardt J, Peacock WF, Emerman CL. Predictors of emergency department observation unit outcomes. Acad Emerg Med. 2005;12:869–74.

    Article  PubMed  Google Scholar 

  13. Collins SP, Lindsell CJ, Naftilan AJ, et al. Low-risk acute heart failure patients: external validation of the Society of Chest Pain Center’s recommendations. Crit Pathw Cardiol. 2009;8:99–103.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Peacock WFT, Emerman CL. Emergency department management of patients with acute decompensated heart failure. Heart Fail Rev. 2004;9:187–93.

    Article  PubMed  Google Scholar 

  15. 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;22:153–64.

    Article  PubMed  CAS  Google Scholar 

  16. Teerlink JR. Dyspnea as an end point in clinical trials of therapies for acute decompensated heart failure. Am Heart J. 2003;145:S26–33.

    Article  PubMed  Google Scholar 

  17. Metra M, Cleland JG, Weatherley BD, et al. Dyspnoea in patients with acute heart failure: an analysis of its clinical course, determinants, and relationship to 60-day outcomes in the PROTECT pilot study. Eur J Heart Fail. 2010;12:499–507.

    Article  PubMed  Google Scholar 

  18. Rostagno C, Gensini GF. Six minute walk test: a simple and useful test to evaluate functional capacity in patients with heart failure. Intern Emerg Med. 2008;3:205–12.

    Article  PubMed  Google Scholar 

  19. Lucas 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;140:840–7.

    Article  PubMed  CAS  Google Scholar 

  20. 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;43:61–7.

    Article  PubMed  Google Scholar 

  21. 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;7:21–9.

    Article  PubMed  CAS  Google Scholar 

  22. Peacock WF. Heart failure management in the emergency department observation unit. Prog Cardiovasc Dis. 2004;46:465–85.

    Article  PubMed  Google Scholar 

  23. 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;37:386–91.

    Article  PubMed  CAS  Google Scholar 

  24. Disomma S, Magrini L, Pittoni V, Marino R, Peacock WF, Maisel A. Usefulness of serial assessment of natriuretic peptides in the emergency department for patients with acute decompensated heart failure. Congest Heart Fail. 2008;14:21–4.

    Article  PubMed  Google Scholar 

  25. Metra M, Nodari S, Parrinello G, et al. The role of plasma biomarkers in acute heart failure. Serial changes and independent prognostic value of NT-proBNP and cardiac troponin-T. Eur J Heart Fail. 2007;9:776–86.

    Article  PubMed  CAS  Google Scholar 

  26. Chittineni H, Miyawaki N, Gulipelli S, Fishbane S. Risk for acute renal failure in patients hospitalized for decompensated congestive heart failure. Am J Nephrol. 2007;27:55–62.

    Article  PubMed  Google Scholar 

  27. Damman K, Navis G, Voors AA, et al. Worsening renal function and prognosis in heart failure: systematic review and meta-analysis. J Card Fail. 2007;13:59–608.

    Article  Google Scholar 

  28. Xue Y, Clopton P, Peacock WF, Maisel AS. Serial changes in high-sensitive troponin I predict outcome in patients with decompensated heart failure. Eur J Heart Fail. 2010;13:37–42.

    Article  PubMed  Google Scholar 

  29. Gotsman I, Zwas D, Planer D, Admon D, Lotan C, Keren A. The significance of serum urea and renal function in patients with heart failure. Medicine. 2010;89:197–203.

    Article  PubMed  CAS  Google Scholar 

  30. Metra M, Teerlink JR, Felker GM, et al. Dyspnoea and worsening heart failure in patients with acute heart failure: results from the Pre-RELAX-AHF study. Eur J Heart Fail. 2010;12:1130–9.

    Article  PubMed  PubMed Central  Google Scholar 

  31. 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;5:247–52.

    Article  PubMed  Google Scholar 

  32. Pan AM, Stiell IG, Clement CM, Acheson J, Aaron SD. Feasibility of a structured 3-minute walk test as a clinical decision tool for patients presenting to the emergency department with acute dyspnoea. Emerg Med J. 2009;26:278–82.

    Article  PubMed  CAS  Google Scholar 

  33. Mebazaa A, Pang PS, Tavares M, et al. The impact of early standard therapy on dyspnoea in patients with acute heart failure: the URGENT-dyspnoea study. Eur Heart J. 2010;31:832–41.

    Article  PubMed  Google Scholar 

  34. Marantz PR, Kaplan MC, Alderman MH. Clinical diagnosis of congestive heart failure in patients with acute dyspnea. Chest. 1990;97:776–81.

    Article  PubMed  CAS  Google Scholar 

  35. Collins SP, Lindsell CJ, Peacock WF, et al. The combined utility of an S3 heart sound and B-type natriuretic peptide levels in emergency department patients with dyspnea. J Card Fail. 2006;12:286–92.

    Article  PubMed  CAS  Google Scholar 

  36. Collins SP, Peacock WF, Lindsell CJ, et al. S3 detection as a diagnostic and prognostic aid in emergency department patients with acute dyspnea. Ann Emerg Med. 2009;53:748–57.

    Article  PubMed  Google Scholar 

  37. Knebel F, Schimke I, Diaz Ramirez I, et al. Hemodynamic improvement of acutely decompensated heart failure patients is associated with decreasing levels of NT-proBNP. Int J Cardiol. 2009;134:260–3.

    Article  PubMed  Google Scholar 

  38. Potluri S, Ventura HO, Mulumudi M, Mehra MR. Cardiac troponin levels in heart failure. Cardiol Rev. 2004;12:21–5.

    Article  PubMed  Google Scholar 

  39. Mueller C. Risk stratification in acute decompensated heart failure: the role of cardiac troponin. Nat Clin Pract Cardiovasc Med. 2008;5:680–1.

    Article  PubMed  CAS  Google Scholar 

  40. Parenti N, Bartolacci S, Carle F, Angelo F. Cardiac troponin I as prognostic marker in heart failure patients discharged from emergency department. Intern Emerg Med. 2008;3:43–7.

    Article  PubMed  Google Scholar 

  41. Lee DS, Austin PC, Rouleau JL, Liu PP, Naimark D, Tu JV. Predicting mortality among patients hospitalized for heart failure: derivation and validation of a clinical model. JAMA. 2003;290:2581–7.

    Article  PubMed  CAS  Google Scholar 

  42. Rusinaru D, Buiciuc O, Leborgne L, Slama M, Massy Z, Tribouilloy C. Relation of serum sodium level to long-term outcome after a first hospitalization for heart failure with preserved ejection fraction. Am J Cardiol. 2009;103:405–10.

    Article  PubMed  CAS  Google Scholar 

  43. Rossi J, Bayram M, Udelson JE, et al. Improvement in hyponatremia during hospitalization for worsening heart failure is associated with improved outcomes: insights from the Acute and Chronic Therapeutic Impact of a Vasopressin Antagonist in Chronic Heart Failure (ACTIV in CHF) trial. Acute Card Care. 2007;9:82–6.

    Article  PubMed  Google Scholar 

  44. Rich MW, Beckham V, Wittenberg C, Leven CL, Freedland KE, Carney RM. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. N Engl J Med. 1995;333:1190–5.

    Article  PubMed  CAS  Google Scholar 

  45. Hanumanthu S, Butler J, Chomsky D, Davis S, Wilson JR. Effect of a heart failure program on hospitalization frequency and exercise tolerance. Circulation. 1997;96:2842–8.

    Article  PubMed  CAS  Google Scholar 

  46. Kim YJ, Soeken KL. A meta-analysis of the effect of hospital-based case management on hospital length-of-stay and readmission. Nurs Res. 2005;54:255–64.

    Article  PubMed  Google Scholar 

  47. Dickstein K, Cohen-Solal A, Filippatos G, et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the diagnosis and treatment of acute and chronic heart failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM). Eur J Heart Fail. 2008;10:933–89.

    Article  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. Department of Emergency Medicine, University of California, Davis Medical Center, Sacramento, CA, USA

    Rachel Rockford MD & Deborah B. Diercks MD, MSc, FACEP

Authors
  1. Rachel Rockford MD
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  2. Deborah B. Diercks MD, MSc, FACEP
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Corresponding author

Correspondence to Deborah B. Diercks MD, MSc, FACEP .

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Editors and Affiliations

  1. Mail Code E-19, Cleveland Clinic Foundation Dept. Emergency Medicine, Cleveland, Ohio, USA

    W. Frank Peacock

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Rockford, R., Diercks, D.B. (2012). Emergency Department and Observation Unit Discharge Criteria. In: Peacock, W. (eds) Short Stay Management of Acute Heart Failure. Contemporary Cardiology. Humana Press, Totowa, NJ. https://doi.org/10.1007/978-1-61779-627-2_16

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  • DOI: https://doi.org/10.1007/978-1-61779-627-2_16

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  • Publisher Name: Humana Press, Totowa, NJ

  • Print ISBN: 978-1-61779-626-5

  • Online ISBN: 978-1-61779-627-2

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