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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.


Predicted probabilities of 30‐day mortality among patients admitted to ICU versus ward, or discharged home. Disch indicates discharge; ICU, intensive care unit.
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jah31644-fig-0002: Predicted probabilities of 30‐day mortality among patients admitted to ICU versus ward, or discharged home. Disch indicates discharge; ICU, intensive care unit.

Mentions: As shown in Table 2, there were small, but statistically significant, differences in laboratory features between groups. The largest difference was presence of troponin higher than the upper limit of normal, which was most prevalent among the ICU cohort. However, there were also smaller differences between groups in the presence of Q‐waves or ST‐depression. The distribution of EHMRG30‐ST predicted probabilities of 30‐day death are shown in Figure 2. The median predicted probabilities (25th, 75th percentiles) of 30‐day death based on the EHMRG30‐ST were 3% (2%, 7%) for ED‐discharged, 5% (2%, 9%) for ward‐admitted, and 6% (3%, 11%) for ICU‐admitted patients (P<0.001).


Care Setting Intensity and Outcomes After Emergency Department Presentation Among Patients With Acute Heart Failure
Predicted probabilities of 30‐day mortality among patients admitted to ICU versus ward, or discharged home. Disch indicates discharge; 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-0002: Predicted probabilities of 30‐day mortality among patients admitted to ICU versus ward, or discharged home. Disch indicates discharge; ICU, intensive care unit.
Mentions: As shown in Table 2, there were small, but statistically significant, differences in laboratory features between groups. The largest difference was presence of troponin higher than the upper limit of normal, which was most prevalent among the ICU cohort. However, there were also smaller differences between groups in the presence of Q‐waves or ST‐depression. The distribution of EHMRG30‐ST predicted probabilities of 30‐day death are shown in Figure 2. The median predicted probabilities (25th, 75th percentiles) of 30‐day death based on the EHMRG30‐ST were 3% (2%, 7%) for ED‐discharged, 5% (2%, 9%) for ward‐admitted, and 6% (3%, 11%) for ICU‐admitted patients (P<0.001).

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&#8208;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&#8208;intensity versus lower&#8208;intensity care settings (ie, ICU vs ward, or ward vs ED&#8208;discharged). Among 9054 patients (median, 78&nbsp;years; 51% men) presenting to an ED in Ontario, Canada, 1163 were ICU&#8208;admitted, 5240 ward&#8208;admitted, and 2651 were ED&#8208;discharged. Predictors of ICU (vs ward) admission included: use of noninvasive positive pressure ventilation (adjusted odds ratio [OR], 2.01; 95% CI, 1.36&ndash;2.98), higher respiratory rate (OR, 1.10 per 5&nbsp;breaths/min; 95% CI, 1.05&ndash;1.15), and lower oxygen saturation (OR, 0.90 per 5%; 95% CI, 0.86&ndash;0.94; all P&lt;0.001). Predictors of ward&#8208;admitted versus ED&#8208;discharged were similar. Propensity&#8208;matched analysis comparing lower&#8208;risk ICU to ward&#8208;admitted patients demonstrated a nonsignificant trend at 100&nbsp;days (relative risk [RR], 0.69; 95% CI, 0.43&ndash;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&ndash;0.94; P=0.022). There was no survival difference among low&#8208;risk ward&#8208;admitted versus ED&#8208;discharged patients.

Conclusions: Respiratory factors were associated with admission to higher&#8208;intensity settings. There was no difference in early survival between some lower&#8208;risk patients admitted to higher&#8208;intensity units compared to those treated in lower&#8208;intensity settings.

No MeSH data available.