Summary

Decisions to admit vs. discharge patients with acute heart failure from the emergency department: consistency with a measure of severity of decompensation and the impact on prognosis

Òscar Miró1, Pere Llorens2, Víctor Gil1, María Pilar López Díez3, Javier Jacob4, Pablo Herrero5, Lluís Llauger6, Josep Tost7, Alfons Aguirre8, Carlos Bibiano9, Marta Fuentes10, María Luisa López Grima11, Rodolfo Romero12, Enrique Martín Mojarro13, Aitor Alquézar Arbé14, Héctor Alonso15, Francisco Javier Martín-Sánchez16

Affiliation of the authors

1Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, Spain. 2Emergency Department, Short Stay and Short Stay and Home Hospitalization Hospital General de Alicante, Health and Biomedical Research Institute of Alicante (ISABIAL), Miguel Hernández University, Alicante, Spain. 3Emergency Department, Hospital Universitario de Burgos, Burgos, Burgos, Spain. 4Emergency Department, Hospital Universitari de Bellvitge, l’Hospitalet de Llobregat, Barcelona, Spain. 5Emergency Department, Hospital Hospital Universitario Central de Asturias, Oviedo, Spain. 6Emergency Department, Hospital Universitari de Vic, Barcelona, Spain. 7Emergency Department, Consorci Hospitalari de Terrassa, Barcelona, Spain. Hospitalari de Terrassa, Barcelona, Spain.8Emergency Department, Hospital del Mar, Barcelona, Spain. 9Emergency Department, Hospital Infanta Leonor, Madrid, Spain. 10Emergency Department, Hospital Universitario de Salamanca, Salamanca, Spain. 11Emergency Department, Hospital Dr. Peset, Valencia, Spain. 12Emergency Department, Hospital de Getafe, Universidad Europea, Madrid, Spain. 13Emergency Department, Hospital Sant Pau i Santa Tecla, Tarragona, Spain. 14Emergency Department, Hospital de la Hospital de la Santa Creu i Sant Pau, Barcelona, Spain. 15Emergency Department, Marqués de Valdecilla Hospital, Santander, Spain. 16Emergency Department, Hospital Clínico San Carlos, Universidad Complutense, Spain.

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Miró O, Llorens P, Gil V, López Díez MP, Jacob J, Herrero P, et al. Decisions to admit vs. discharge patients with acute heart failure from the emergency department: consistency with a measure of severity of decompensation and the impact on prognosis. Emergencias. 2023;35:261-9

Summary

Objectives.

To analyze the consistency between decisions to discharge or admit patients with acute heart failure (AHF) treated in emergency departments (EDs) and the level of risk of adverse events, and to analyze the impact of decisions to discharge patients.

Methods.

Prospective study of baseline clinical data collected from patients diagnosed with AHF in 16 Spanish emergency departments. Patients were stratified by severity of decompensated AHF based on MEESSI assessment (Multiple Estimation of Risk Based on the Spanish Emergency Department Score). The distribution of severity was described for patients who were hospitalized (overall and for departments receiving the largest number of admissions) and for discharged patients. We analyzed the data for discharged patients for associations with the following quality-of-care indicators: all-cause mortality of less than 2% at 30 days, revisits to the ED for AHF in less than 10% of patients within 7 days of discharge, and revisits to the ED or admission for AHF in less than 20% within 30 days of discharge.

Results.

We included 2855 patients with a median (interquartile range) age of 84 (76-88) years. Fifty-four percent were women, 1042 (36.5%) were classified as low risk, 1239 (43.4%) as intermediate risk, 301 (10.5%) as high risk, and 273 (9.6%) as very high risk. Thirty day mortality rates by level of low to very high risk were 1.9%, 9.3%, 15.3%, and 38.4%, respectively. One-year mortality rates by risk level were 15.4%, 35.6%, 52.0%, and 74.2%. Admission rates by risk level were 62.2%, 77.4%, 87.0%, and 88.3%. Overall, 47.1% o patients discharged from the ED were in the 3 higher-risk categories (intermediate to very high), and 30.7% were in the lowest risk category. The 5 hospital areas receiving the most admissions, in order of lowest-to-highest risk classification, were internal medicine, the short-stay unit, cardiology, intensive care, and geriatrics. Rates and 95% CIs for quality-of-care indicators in patients discharged from EDs were as follows: 30-day mortality, 4.3% (3.0%-6.1%); ED revisits within 7 days, 11.4% (9.2%-14.0%), and ED revisits or admissions within 30 days, 31.5% (28.0%-35.1%). In patients classified as low risk on ED discharge, these percentages were lower, as follows, respectively: 0.5% (0.1%-1.8%), 10.5% (7.6%-14.0%), and 29.5% (26.6%-32.6%).

Conclusions.

We detected disparity between severity of AHF decompensation and the decision to discharge or admit patients. Outcomes in patients discharged from EDs do not reach the recommended quality-of-care standards. Reducing inconsistencies between severity of decompensation and ED decisions could help to improve quality targets.

 

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