LO02: Development of the HEARTRISK6 Scale for emergency department patients with acute heart failure

Introduction: We previously derived (N = 559) and validated (N = 1,100) the 10-item Ottawa Heart Failure Risk Scale (OHFRS), to assist with disposition decisions for patients with acute heart failure (AHF) in the emergency department (ED). In the current study we sought to use a larger dataset to develop a more concise and more accurate risk scale. Methods: We analyzed data from the prior two studies and from a new cohort. For all 3 groups we conducted prospective cohort studies that enrolled patients who required treatment for AHF at 8 tertiary care hospital EDs. Patients were followed for 30 days. The primary outcome was short-term serious outcome (SSO), defined as death within 30 days, intubation or non-invasive ventilation (NIV) after admission, myocardial infarction, or relapse resulting in hospital admission within 14 days. The fully pre-specified logistic regression model with 13 predictors (where age, pCO2, and SaO2 were modeled using spline functions) was fitted to 10 multiple imputation datasets. Harrell's fast stepdown procedure reduced the number of variables. We calculated the potential impact on sensitivity (95% CI) for SSO and hospital admissions, and estimated a sample size of 2,000 patients. Results: The 1,986 patients had mean age 77.3 years, male 54.1%, EMS arrival 41.2%, IV NTG 3.3%, ED NIV 5.4%, admission on initial visit 49.5%. Overall there were 236 (11.9%) SSOs including 61 deaths (3.1%), meaning that current admission practice sensitivity for SSO was only 59.7%. The final HEARTRISK6 scale is comprised of 6 variables (points) (C-statistic 0.68): Valvular heart disease (2) Antiarrhythmic medication (2) ED non-invasive ventilation (3) Creatinine 80–150 (1); ≥150 (3) Troponin ≥3x URL (2) Walk test failed (1). The probability of SSO ranged from 4.8% for a total score of 0 to 62.4% for a score of 10, showing good calibration. Choosing a HEARTRISK6 total point admission threshold of ≥3 would yield sensitivity of 70.8% (95%CI 64.5-76.5) for SSO with a slight decrease in admissions to 47.9%. Choosing a threshold of ≥2 would yield a sensitivity of 84.3% (95%CI 79.0-88.7) but require 66.6% admissions. Conclusion: Using a large prospectively collected dataset, we created a more concise and more sensitive risk scale to assist with admission decisions for patients with AHF in the ED. Implementation of the HEARTRISK6 scale should lead to safer and more efficient disposition decisions, with more high-risk patients being admitted and more low-risk patients being discharged.

Download Full-text

PL01: Creation of a risk scoring system for emergency department patients with acute heart failure

CJEM ◽

10.1017/cem.2020.46 ◽

2020 ◽

Vol 22 (S1) ◽

pp. S5-S5

Author(s):

I. Stiell ◽

J. Perry ◽

C. Clement ◽

S. Sibley ◽

A. McRae ◽

...

Keyword(s):

Heart Failure ◽

Emergency Department ◽

Acute Heart Failure ◽

Care Hospital ◽

Invasive Ventilation ◽

Non Invasive ◽

Non Invasive Ventilation ◽

Risk Patients ◽

Risk Scoring ◽

Risk Scale

Introduction: Acute heart failure (AHF) is a common emergency department (ED) presentation and may be associated with poor outcomes. Conversely, many patients rapidly improve with ED treatment and may not need hospital admission. Because there is little evidence to guide disposition decisions by ED and admitting physicians, we sought to create a risk score for predicting short-term serious outcomes (SSO) in patients with AHF. Methods: We conducted prospective cohort studies at 9 tertiary care hospital EDs from 2007 to 2019, and enrolled adult patients who required treatment for AHF. Each patient was assessed for standardized real-time clinical and laboratory variables, as well as for SSO (defined as death within 30 days or intubation, non-invasive ventilation (NIV), myocardial infarction, coronary bypass surgery, or new hemodialysis after admission). The fully pre-specified, logistic regression model with 13 predictors (age, pCO2, and SaO2 were modeled using spline functions with 3 knots and heart rate and creatinine with 5 knots) was fitted to the 10 multiple imputation datasets. Harrell's fast stepdown procedure reduced the number of variables. We calculated the potential impact on sensitivity (95% CI) for SSO and hospital admissions and estimated a sample size of 170 SSOs. Results: The 2,246 patients had mean age 77.4 years, male sex 54.5%, EMS arrival 41.1%, IV NTG 3.1%, ED NIV 5.2%, admission on initial visit 48.6%. Overall there were 174 (7.8%) SSOs including 70 deaths (3.1%). The final risk scale is comprised of five variables (points) and had c-statistic of 0.76 (95% CI: 0.73-0.80): 1.Valvular heart disease (1) 2.ED non-invasive ventilation (2) 3.Creatinine 150-300 (1) ≥300 (2) 4.Troponin 2x-4x URL (1) ≥5x URL (2) 5.Walk test failed (2) The probability of SSO ranged from 2.0% for a total score of 0 to 90.2% for a score of 10, showing good calibration. The model was stable over 1,000 bootstrap samples. Choosing a risk model total point admission threshold of >2 would yield a sensitivity of 80.5% (95% CI 73.9-86.1) for SSO with no change in admissions from current practice (48.6% vs 48.7%). Conclusion: Using a large prospectively collected dataset, we created a concise and sensitive risk scale to assist with admission decisions for patients with AHF in the ED. Implementation of this risk scoring scale should lead to safer and more efficient disposition decisions, with more high-risk patients being admitted and more low-risk patients being discharged.

Download Full-text

Effects on short term outcome of non-invasive ventilation use in the emergency department to treat patients with acute heart failure: A propensity score-based analysis of the EAHFE Registry

European Journal of Internal Medicine ◽

10.1016/j.ejim.2018.03.008 ◽

2018 ◽

Vol 53 ◽

pp. 45-51 ◽

Cited By ~ 4

Author(s):

Òscar Miró ◽

Gemma Martínez ◽

Josep Masip ◽

Víctor Gil ◽

Francisco Javier Martín-Sánchez ◽

...

Keyword(s):

Heart Failure ◽

Emergency Department ◽

Propensity Score ◽

Acute Heart Failure ◽

Invasive Ventilation ◽

Short Term ◽

Term Outcome ◽

Non Invasive ◽

Short Term Outcome ◽

Non Invasive Ventilation

Download Full-text

Safety and Efficacy of Aerobic Exercise Training Associated to Non-Invasive Ventilation in Patients with Acute Heart Failure

Arquivos Brasileiros de Cardiologia ◽

10.5935/abc.20180039 ◽

2018 ◽

Cited By ~ 1

Author(s):

Mayron F. Oliveira ◽

Rita C. Santos ◽

Suellen A. Artz ◽

Vanessa M. F. Mendez ◽

Denise M. L. Lobo ◽

...

Keyword(s):

Heart Failure ◽

Exercise Training ◽

Aerobic Exercise ◽

Acute Heart Failure ◽

Aerobic Exercise Training ◽

Invasive Ventilation ◽

Safety And Efficacy ◽

Non Invasive ◽

Non Invasive Ventilation

Download Full-text

Risk of COVID-19 Infection in Healthcare Workers Exposed During Use of Non-invasive Ventilation in a Tertiary Care Hospital in OmanRisk of COVID-19 Infection in Healthcare Workers Exposed During Use of Non-invasive Ventilation in a Tertiary Care Hospital in Oman

Oman Medical Journal ◽

10.5001/omj.2021.110 ◽

2021 ◽

Vol 36 (2) ◽

pp. e236-e236

Author(s):

Adil Al Lawati ◽

Faryal Khamis ◽

Samiha Al Habsi ◽

Khazina Al Dalhami

Keyword(s):

High Risk ◽

Healthcare Workers ◽

Tertiary Care Hospital ◽

Tertiary Care ◽

Significant Risk ◽

High Risk Population ◽

Care Hospital ◽

Invasive Ventilation ◽

Non Invasive ◽

Non Invasive Ventilation

Objectives: Healthcare workers (HCWs), especially those working on the front line, are considered to be at high risk of nosocomial acquisition of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease 2019 (COVID-19). Little is known about the effectiveness of the recommended protective methods as few reports have described spread of the disease in hospital settings among this high-risk population. We describe the hospital-based transmission of SARS-CoV-2 related to non-invasive ventilation (NIV) in one of the main tertiary care hospitals in Oman. Methods: All exposed patients and HCWs from Royal Hospital were screened, quarantined, and underwent telephone interviews to stratify their risk factors, clinical symptoms, and exposure risk assessment. Results: A total of 46 HCWs and patients tested positive for SARS-CoV-2 after exposure to an index case who received 48 hours of NIV before diagnosing COVID-19 infection. Over half of the exposed (56.5%; n = 26) were nurses, 26.1% (n = 12) were patients, and 15.2% (n = 7) were doctors. None of the HCWs required hospitalization. Sore throat, fever, and myalgia were the most common symptoms. Conclusions: NIV poses a significant risk for SARS-CoV-2 transmission within hospital settings if appropriate infection control measures are not taken.

Download Full-text

LO14: Interdepartmental program to improve outcomes for acute heart failure patients seen in the emergency department

CJEM ◽

10.1017/cem.2020.70 ◽

2020 ◽

Vol 22 (S1) ◽

pp. S11-S12

Author(s):

I. Stiell ◽

M. Taljaard ◽

A. Forster ◽

L. Mielniczuk ◽

G. Wells ◽

...

Keyword(s):

Heart Failure ◽

Emergency Department ◽

Acute Heart Failure ◽

Hospital Admissions ◽

Tertiary Care ◽

Control Period ◽

Care Hospital ◽

Index Visit ◽

Rapid Access

Introduction: An important challenge physicians face when treating acute heart failure (AHF) patients in the emergency department (ED) is deciding whether to admit or discharge, with or without early follow-up. The overall goal of our project was to improve care for AHF patients seen in the ED while avoiding unnecessary hospital admissions. The specific goal was to introduce hospital rapid referral clinics to ensure AHF patients were seen within 7 days of ED discharge. Methods: This prospective before-after study was conducted at two campuses of a large tertiary care hospital, including the EDs and specialty outpatient clinics. We enrolled AHF patients ≥50 years who presented to the ED with shortness of breath (<7 days). The 12-month before (control) period was separated from the 12-month after (intervention) period by a 3-month implementation period. Implementation included creation of rapid access AHF clinics staffed by cardiology and internal medicine, and development of referral procedures. There was extensive in-servicing of all ED staff. The primary outcome measure was hospital admission at the index visit or within 30 days. Secondary outcomes included mortality and actual access to rapid follow-up. We used segmented autoregression analysis of the monthly proportions to determine whether there was a change in admissions coinciding with the introduction of the intervention and estimated a sample size of 700 patients. Results: The patients in the before period (N = 355) and the after period (N = 374) were similar for age (77.8 vs. 78.1 years), arrival by ambulance (48.7% vs 51.1%), comorbidities, current medications, and need for non-invasive ventilation (10.4% vs. 6.7%). Comparing the before to the after periods, we observed a decrease in hospital admissions on index visit (from 57.7% to 42.0%; P <0.01), as well as all admissions within 30 days (from 65.1% to 53.5% (P < 0.01). The autoregression analysis, however, demonstrated a pre-existing trend to fewer admissions and could not attribute this to the intervention (P = 0.91). Attendance at a specialty clinic, amongst those discharged increased from 17.8% to 42.1% (P < 0.01) and the median days to clinic decreased from 13 to 6 days (P < 0.01). 30-day mortality did not change (4.5% vs. 4.0%; P = 0.76). Conclusion: Implementation of rapid-access dedicated AHF clinics led to considerably increased access to specialist care, much reduced follow-up times, and possible reduction in hospital admissions. Widespread use of this approach can improve AHF care in Canada.

Download Full-text