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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

Multivariable predictors of hospitalization in the ICU (vs ward) with P<0.05 in multivariable model. OR >1 indicates higher odds of ICU admission. bpm indicates beats per minute; CV, cardiovascular; ED, emergency department; EMS, emergency medical services; ICU, intensive care unit; MI myocardial infarction; NH, nursing home; NPPV, noninvasive positive pressure ventilation; OR, odds ratio.
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jah31644-fig-0004: Multivariable predictors of hospitalization in the ICU (vs ward) with P<0.05 in multivariable model. OR >1 indicates higher odds of ICU admission. bpm indicates beats per minute; CV, cardiovascular; ED, emergency department; EMS, emergency medical services; ICU, intensive care unit; MI myocardial infarction; NH, nursing home; NPPV, noninvasive positive pressure ventilation; OR, odds ratio.

Mentions: Among patients who were admitted, several patient characteristics were associated with ICU rather than ward admission. Multivariable predictors of admission to the ICU (vs ward) are shown in Figure 4 (c‐statistic=0.770). Accounting for clustering within hospitals, factors that were associated with ICU admission (adjusted OR >1) included previous MI, higher heart rate, higher creatinine concentration, and wider QRS duration. Respiratory factors (higher respiratory rate, lower oxygen saturation, and use of NPPV) were also associated with ICU admission. The presence of ST‐depression on ECG and serum sodium concentration were not associated with ICU (vs ward) admission. Interestingly, higher SBP was associated with ICU admission, although SBP <90 mm Hg exhibited a nonsignificant trend, with an adjusted OR of 1.45 (95% CI, 0.82, 2.57). Occurrence of a complication in the ED was associated with higher odds of ICU compared to ward admission (OR, 5.92; 95% CI, 4.19, 8.35; P<0.001). Presentation at a teaching hospital was associated with lower odds of ICU admission than community hospitals after multivariable adjustment.


Care Setting Intensity and Outcomes After Emergency Department Presentation Among Patients With Acute Heart Failure
Multivariable predictors of hospitalization in the ICU (vs ward) with P<0.05 in multivariable model. OR >1 indicates higher odds of ICU admission. bpm indicates beats per minute; CV, cardiovascular; ED, emergency department; EMS, emergency medical services; ICU, intensive care unit; MI myocardial infarction; NH, nursing home; NPPV, noninvasive positive pressure ventilation; OR, odds ratio.
© Copyright Policy - creativeCommonsBy-nc-nd
Related In: Results  -  Collection

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

jah31644-fig-0004: Multivariable predictors of hospitalization in the ICU (vs ward) with P<0.05 in multivariable model. OR >1 indicates higher odds of ICU admission. bpm indicates beats per minute; CV, cardiovascular; ED, emergency department; EMS, emergency medical services; ICU, intensive care unit; MI myocardial infarction; NH, nursing home; NPPV, noninvasive positive pressure ventilation; OR, odds ratio.
Mentions: Among patients who were admitted, several patient characteristics were associated with ICU rather than ward admission. Multivariable predictors of admission to the ICU (vs ward) are shown in Figure 4 (c‐statistic=0.770). Accounting for clustering within hospitals, factors that were associated with ICU admission (adjusted OR >1) included previous MI, higher heart rate, higher creatinine concentration, and wider QRS duration. Respiratory factors (higher respiratory rate, lower oxygen saturation, and use of NPPV) were also associated with ICU admission. The presence of ST‐depression on ECG and serum sodium concentration were not associated with ICU (vs ward) admission. Interestingly, higher SBP was associated with ICU admission, although SBP <90 mm Hg exhibited a nonsignificant trend, with an adjusted OR of 1.45 (95% CI, 0.82, 2.57). Occurrence of a complication in the ED was associated with higher odds of ICU compared to ward admission (OR, 5.92; 95% CI, 4.19, 8.35; P<0.001). Presentation at a teaching hospital was associated with lower odds of ICU admission than community hospitals after multivariable adjustment.

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.


Related in: MedlinePlus