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Care Setting Intensity and Outcomes After Emergency Department Presentation Among Patients With Acute Heart Failure

View Article: PubMed Central - PubMed

ABSTRACT

Background: Patients with heart failure (HF) presenting to the emergency department (ED) can be admitted to care settings of different intensity, where the intensive care unit (ICU) is the highest intensity, ward admission is intermediate intensity, and those discharged home are of lowest intensity. Despite the costs associated with higher‐intensity care, little is known about disposition decisions and outcomes of HF patients treated in different care settings.

Methods and results: We identified predictors of ICU or ward admission and determined whether survival differs in patients admitted to higher‐intensity versus lower‐intensity care settings (ie, ICU vs ward, or ward vs ED‐discharged). Among 9054 patients (median, 78 years; 51% men) presenting to an ED in Ontario, Canada, 1163 were ICU‐admitted, 5240 ward‐admitted, and 2651 were ED‐discharged. Predictors of ICU (vs ward) admission included: use of noninvasive positive pressure ventilation (adjusted odds ratio [OR], 2.01; 95% CI, 1.36–2.98), higher respiratory rate (OR, 1.10 per 5 breaths/min; 95% CI, 1.05–1.15), and lower oxygen saturation (OR, 0.90 per 5%; 95% CI, 0.86–0.94; all P<0.001). Predictors of ward‐admitted versus ED‐discharged were similar. Propensity‐matched analysis comparing lower‐risk ICU to ward‐admitted patients demonstrated a nonsignificant trend at 100 days (relative risk [RR], 0.69; 95% CI, 0.43–1.10; P=0.148). At 1 year, however, survival was higher among those initially admitted to ICU (RR, 0.68; 95% CI, 0.49–0.94; P=0.022). There was no survival difference among low‐risk ward‐admitted versus ED‐discharged patients.

Conclusions: Respiratory factors were associated with admission to higher‐intensity settings. There was no difference in early survival between some lower‐risk patients admitted to higher‐intensity units compared to those treated in lower‐intensity settings.

No MeSH data available.


Related in: MedlinePlus

Flow diagram of the study cohort. AMA indicates against medical advice; CCU, coronary care unit; DNR, do not resuscitate; ED, emergency department; EFFECT, Enhanced Feedback For Effective Cardiac Treatment; EHMRG, Emergency Heart failure Mortality Risk Grade; ICU, intensive care unit.
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jah31644-fig-0001: Flow diagram of the study cohort. AMA indicates against medical advice; CCU, coronary care unit; DNR, do not resuscitate; ED, emergency department; EFFECT, Enhanced Feedback For Effective Cardiac Treatment; EHMRG, Emergency Heart failure Mortality Risk Grade; ICU, intensive care unit.

Mentions: From among 13 568 patients meeting Framingham criteria for HF, 4514 were excluded, resulting in a final study cohort of 9054 patients (see Figure 1 for flow diagram and exclusions). Approximately one third of the study population was discharged from the ED. Among those admitted to the hospital, 18.1% were admitted to the ICU. The clinical characteristics of the cohort according to ED disposition are shown in Table 1. Overall, median age was 78 years (69, 84) and 4441 (49.1%) were women. Patients admitted to higher‐intensity units (ICU > ward > discharge) demonstrated worse physiological severity, with higher heart rate and respiratory rate and lower oxygen saturation. Cardiovascular disease risk factors and coronary artery disease were more prevalent with increasing care intensity setting. Evidence‐based HF medication profile before presentation was similar among allocation groups, except for the use of diuretics, which was highest among those discharged from the ED.


Care Setting Intensity and Outcomes After Emergency Department Presentation Among Patients With Acute Heart Failure
Flow diagram of the study cohort. AMA indicates against medical advice; CCU, coronary care unit; DNR, do not resuscitate; ED, emergency department; EFFECT, Enhanced Feedback For Effective Cardiac Treatment; EHMRG, Emergency Heart failure Mortality Risk Grade; ICU, intensive care unit.
© Copyright Policy - creativeCommonsBy-nc-nd
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC5015368&req=5

jah31644-fig-0001: Flow diagram of the study cohort. AMA indicates against medical advice; CCU, coronary care unit; DNR, do not resuscitate; ED, emergency department; EFFECT, Enhanced Feedback For Effective Cardiac Treatment; EHMRG, Emergency Heart failure Mortality Risk Grade; ICU, intensive care unit.
Mentions: From among 13 568 patients meeting Framingham criteria for HF, 4514 were excluded, resulting in a final study cohort of 9054 patients (see Figure 1 for flow diagram and exclusions). Approximately one third of the study population was discharged from the ED. Among those admitted to the hospital, 18.1% were admitted to the ICU. The clinical characteristics of the cohort according to ED disposition are shown in Table 1. Overall, median age was 78 years (69, 84) and 4441 (49.1%) were women. Patients admitted to higher‐intensity units (ICU > ward > discharge) demonstrated worse physiological severity, with higher heart rate and respiratory rate and lower oxygen saturation. Cardiovascular disease risk factors and coronary artery disease were more prevalent with increasing care intensity setting. Evidence‐based HF medication profile before presentation was similar among allocation groups, except for the use of diuretics, which was highest among those discharged from the ED.

View Article: PubMed Central - PubMed

ABSTRACT

Background: Patients with heart failure (HF) presenting to the emergency department (ED) can be admitted to care settings of different intensity, where the intensive care unit (ICU) is the highest intensity, ward admission is intermediate intensity, and those discharged home are of lowest intensity. Despite the costs associated with higher‐intensity care, little is known about disposition decisions and outcomes of HF patients treated in different care settings.

Methods and results: We identified predictors of ICU or ward admission and determined whether survival differs in patients admitted to higher‐intensity versus lower‐intensity care settings (ie, ICU vs ward, or ward vs ED‐discharged). Among 9054 patients (median, 78 years; 51% men) presenting to an ED in Ontario, Canada, 1163 were ICU‐admitted, 5240 ward‐admitted, and 2651 were ED‐discharged. Predictors of ICU (vs ward) admission included: use of noninvasive positive pressure ventilation (adjusted odds ratio [OR], 2.01; 95% CI, 1.36–2.98), higher respiratory rate (OR, 1.10 per 5 breaths/min; 95% CI, 1.05–1.15), and lower oxygen saturation (OR, 0.90 per 5%; 95% CI, 0.86–0.94; all P<0.001). Predictors of ward‐admitted versus ED‐discharged were similar. Propensity‐matched analysis comparing lower‐risk ICU to ward‐admitted patients demonstrated a nonsignificant trend at 100 days (relative risk [RR], 0.69; 95% CI, 0.43–1.10; P=0.148). At 1 year, however, survival was higher among those initially admitted to ICU (RR, 0.68; 95% CI, 0.49–0.94; P=0.022). There was no survival difference among low‐risk ward‐admitted versus ED‐discharged patients.

Conclusions: Respiratory factors were associated with admission to higher‐intensity settings. There was no difference in early survival between some lower‐risk patients admitted to higher‐intensity units compared to those treated in lower‐intensity settings.

No MeSH data available.


Related in: MedlinePlus