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

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.

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2481 A collaborative neurology-emergency medicine rapid outpatient clinic for the management of TIA and minor stroke in the emergency department

Journal of Clinical and Translational Science ◽

10.1017/cts.2018.153 ◽

2018 ◽

Vol 2 (S1) ◽

pp. 37-37

Author(s):

Bernard P. Chang ◽

Rachel Mehendale ◽

Eliza Miller ◽

Benjamin Kummer ◽

Joshua Willey ◽

...

Keyword(s):

Emergency Department ◽

Hospital Admissions ◽

Tertiary Care ◽

Low Risk ◽

Minor Stroke ◽

Decision Tool ◽

Inpatient Hospitalization ◽

Rapid Access ◽

Rapid Access Clinic

OBJECTIVES/SPECIFIC AIMS: Current practice frequently dictates hospitalization for TIA and minor stroke (TIAMS) in order to obtain comprehensive evaluation of stroke risk factors and mechanism. Inpatient hospitalization is often done to expedite workup and to coordinate care although may be associated with nosocomial risks and increased healthcare cost. However, a subset of these patients who do not have debilitating deficits may not require inpatient hospitalization. We conducted a pilot study to assess the feasibility of conducting rapid outpatient stroke evaluations in low risk patients with TIAMS without disabling deficits. METHODS/STUDY POPULATION: The rapid access clinic was initiated at a single-site urban tertiary care facility for outpatient evaluation of TIAMS within 24 hours of emergency department (ED) evaluation. Patients were selected using a decision tool identifying presumed low-risk TIAMS seen in the ED. Criteria included medical (e.g., no disabling deficit, no thrombolytic agent given, negative CT for hemorrhagic stroke) as well as social criteria (e.g., patient ability to follow-up as an outpatient). We evaluated rates of noncompliance with post-ED follow-up, need for hospitalization from clinic, and 90 day stroke and health outcome data. RESULTS/ANTICIPATED RESULTS: Between December 2016 and December 2017 a total of 93 TIAMS patients seen in the ED were recommended for the rapid access clinic utilizing the decision tool. Of these patients, 94.5% (86) were evaluated within 24 hours of ED discharge. Only 2 patients (2.4%) who received outpatient evaluation required hospitalization; 61 (71.8%) patients had TIAMS on final evaluation in clinic. DISCUSSION/SIGNIFICANCE OF IMPACT: Our pilot data suggests that for a subset of patients, rapid outpatient evaluation may be a feasible and safe strategy for TIAMS management. Future work exploring such strategies may help improve TIAMS outcomes and reduce ED crowding and unnecessary hospital admissions.

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

CJEM ◽

10.1017/cem.2019.45 ◽

2019 ◽

Vol 21 (S1) ◽

pp. S7

Author(s):

I. Stiell ◽

A. McRae ◽

B. Rowe ◽

J. Dreyer ◽

L. Mielniczuk ◽

...

Keyword(s):

Heart Failure ◽

Emergency Department ◽

Acute Heart Failure ◽

Tertiary Care ◽

Care Hospital ◽

Invasive Ventilation ◽

Non Invasive ◽

Non Invasive Ventilation ◽

Risk Patients ◽

Risk Scale

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.

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Health care provided to recent asylum-seeking and non-asylum-seeking pediatric patients in 2016 and 2017 at a Swiss tertiary hospital - a retrospective study

10.21203/rs.3.rs-22231/v3 ◽

2020 ◽

Author(s):

Julia Brandenberger ◽

Christian Pohl ◽

Florian Vogt ◽

Thorkild Tylleskär ◽

Nicole Ritz

Keyword(s):

Health Care ◽

Emergency Department ◽

Retrospective Study ◽

Hospital Admissions ◽

Tertiary Care ◽

Median Number ◽

Care Hospital ◽

Children With Medical Complexity ◽

Cross Sectional ◽

Number Of Visits

Abstract BackgroundAsylum-seeking children represent an increasing and vulnerable group of patients whose health needs are largely unmet. Data on the health care provision to asylum-seeking children in European contexts is scarce. In this study we compare the health care provided to recent asylum-seeking and non-asylum-seeking children at a Swiss tertiary hospital.MethodsWe performed a cross-sectional retrospective study in a pediatric tertiary care hospital in Basel, Switzerland. All patients and visits from January 2016 to December 2017 were identified, using administrative and medical electronic health records. The asylum-seeking status was systematically assessed and the patients were allocated accordingly in the two study groups.Results A total of 202,316 visits by 55,789 patients were included, of which asylum-seeking patients accounted for 1674 (1%) visits by 439 (1%) individuals. The emergency department recorded the highest number of visits in both groups with a lower proportion in asylum-seeking compared to non-asylum-seeking children: 19% (317/1674) and 32% (64,315/200,642) respectively. The median number of visits per patient was 1 (IQR 1-2) in the asylum-seeking and 2 (IQR 1-4) in the non-asylum-seeking children. Hospital admissions were more common in asylum-seeking compared to non-asylum-seeking patients with 11% (184/1674) and 7% (14,692/200,642). Frequent visits (>15 visits per patient) accounted for 48% (807/1674) of total visits in asylum-seeking and 25% (49,886/200,642) of total visits in non-asylum-seeking patients. ConclusionsHospital visits by asylum-seeking children represented a small proportion of all visits. The emergency department had the highest number of visits in all patients but was less frequently used by asylum-seeking children. Frequent care suggests that asylum-seeking patients also present with more complex diseases. Further studies are needed, focusing on asylum-seeking children with medical complexity.

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Chest Pain in Emergency Department Patients: If the Pain is Relieved by Nitroglycerin, is it More Likely to be Cardiac Chest Pain?

CJEM ◽

10.1017/s1481803500013671 ◽

2006 ◽

Vol 8 (03) ◽

pp. 164-169 ◽

Cited By ~ 9

Author(s):

Robert Steele ◽

Timothy McNaughton ◽

Melissa McConahy ◽

John Lam

Keyword(s):

Coronary Artery Disease ◽

Emergency Department ◽

Chest Pain ◽

Coronary Artery ◽

Diagnostic Test ◽

Tertiary Care ◽

Positive Likelihood Ratio ◽

Care Hospital ◽

Artery Disease

ABSTRACT Introduction: It is often believed that chest pain relieved by nitroglycerin is indicative of coronary artery disease origin. Objective: To determine if relief of chest pain with nitroglycerin can be used as a diagnostic test to help differentiate cardiac chest pain and non-cardiac chest pain. Design: Prospective observational cohort study with a 4-week follow-up of patients enrolled. Setting: Academic tertiary care hospital, with 60 000 visits/year. Inclusion criteria: Adult patients presenting to the emergency department with active chest pain who received nitroglycerin and were admitted for chest pain. Exclusion criteria: Patients with acute myocardial infarction diagnosed after obtaining an ECG, patients whose chest pain could not be quantified, those for whom no cardiac work-up was done, or those who received emergent cardiac catheterization. Results: 270 patients were enrolled. Nitroglycerin relieved chest pain in 66% of the subjects. The diagnostic sensitivity of nitroglycerin to determine cardiac chest pain was 72% (64%–80%), and the specificity was 37% (34%–41%). The positive likelihood ratio for having coronary artery disease if nitroglycerin relieved chest pain was 1.1 (0.96–1.34). Telephone follow-up at 4 weeks was performed, with a 95% follow-up rate. Conclusions: Relief of chest pain with nitroglycerin is not a reliable diagnostic test and does not distinguish between cardiac and non-cardiac chest pain.

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Recurrent Emergency Department Users: Two Categories with Different Risk Profiles

Journal of Clinical Medicine ◽

10.3390/jcm8030333 ◽

2019 ◽

Vol 8 (3) ◽

pp. 333 ◽

Cited By ~ 4

Author(s):

Ksenija Slankamenac ◽

Meret Zehnder ◽

Tim Langner ◽

Kathrin Krähenmann ◽

Dagmar Keller

Keyword(s):

Risk Factors ◽

Emergency Department ◽

Emergency Services ◽

Hospital Admissions ◽

Tertiary Care ◽

Chronic Obstructive ◽

Care Hospital ◽

Co Morbidity ◽

Ed Visits ◽

Morbidity Index

Recurrent emergency department (ED) visits are responsible for an increasing proportion of overcrowding. Therefore, our aim was to investigate the characteristics and prevalence of recurrent ED visitors as well as to determine risk factors associated with multiple ED visits. ED patients visiting the ED of a tertiary care hospital at least four times consecutively in 2015 were enrolled. Of 33,335 primary ED visits, 1921 ED visits (5.8%) were performed by 372 ED patients who presented in the ED at least four times within the one-year period. Two different categories of recurrent ED patients were identified: repeated ED users presenting always with the same symptoms and frequent ED visitors who were suffering from different symptoms on each ED visit. Repeated ED users had more ED visits (p < 0.001) and needed more hospital admissions (p < 0.010) compared to frequent ED users. Repeated ED users visited the ED more likely due to symptoms from chronic obstructive pulmonary diseases (p < 0.001) and mental disorders (p < 0.001). In contrast, frequent ED patients showed to be at risk for multiple ED visits when being disabled (p = 0.001), had an increased Charlson co-morbidity index (p = 0.004) or suffering from rheumatic diseases (p < 0.001). A small number of recurrent ED visitors determines a relevant number of ED visits with a relevance for and impact on patient centred care and emergency services. There are two categories of recurrent ED users with different risk factors for multiple ED visits: repeated and frequent. Therefore, multi-professional follow-up care models for recurrent ED patients are needed to improve patients’ needs, quality of life as well as emergency services.

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Early and comprehensive care bundle in elderly for acute heart failure in the emergency department: study protocol of The ELISABETH stepped wedge cluster randomized trial

10.21203/rs.2.123/v1 ◽

2018 ◽

Author(s):

Yonathan Freund ◽

Judith Gorlick ◽

Marine Cachanado ◽

Sarah Salhi ◽

Vanessa Lemaitre ◽

...

Keyword(s):

Heart Failure ◽

Emergency Department ◽

Elderly Patients ◽

Acute Heart Failure ◽

Control Period ◽

Care Bundle ◽

Stepped Wedge ◽

Precipitating Factors ◽

Intervention Period ◽

Cluster Randomized

Abstract Background: Acute heart failure (AHF) is one of the most common diagnoses for elderly patients in the emergency department (ED), with an admission rate higher than 80% and 1-month mortality around 10%. The European guidelines for the management of AHF are based on moderate levels of evidence, due to the lack of randomized controlled trials and the scarce evidence of any clinical added value of a specific treatment to improve outcomes. Recent reports suggest that the very early administration of full recommended therapy may decrease mortality. However, several studies highlighted that elderly patients often received suboptimal treatment. Our hypothesis is that an early care bundle that comprises early and comprehensive management of symptoms, along with prompt detection and treatment of precipitating factors should improve AHF outcome in elderly patients. Method/design: ELISABETH is a stepped-wedge, controlled cluster randomized, clinical trial in 15 emergency departments in France recruiting all patients aged 75 years and older with a diagnosis of AHF. The tested intervention is a care bundle with a checklist that mandates detection and early treatment of AHF precipitating factors, early and intensive treatment of congestion with intravenous nitrates boluses, and application of other recommended treatment (low dose diuretics, non-invasive ventilation when indicated, and preventive low molecular weight heparin). Each centre are randomized to the order in which they will switch from “control period” to “intervention period”. All centers begin the trials with the control period for two weeks, then after each two-weeks step a new centre will be in the intervention period. At the end of the trial, all clusters will receive the intervention regimen. The primary outcome is the number of days alive and out of the hospital at 30 days. Discussion: If our hypothesis is confirmed, this trial will strengthen the level of evidence of AHF guidelines and stress the importance of the associated early and comprehensive treatment of precipitating factors. This trial could be the first to report a reduction in short term morbidity and mortality in elderly AHF patients. Registration: NCT03683212, prospectively registered on September 25th 2018 Keywords: Elderly, acute heart failure, emergency department

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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.

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Acute heart failure in the emergency department: a follow-up study

Internal and Emergency Medicine ◽

10.1007/s11739-015-1336-z ◽

2015 ◽

Vol 11 (1) ◽

pp. 115-122 ◽

Cited By ~ 4

Author(s):

Andrea Fabbri ◽

Giulio Marchesini ◽

Giorgio Carbone ◽

Roberto Cosentini ◽

Annamaria Ferrari ◽

...

Keyword(s):

Heart Failure ◽

Emergency Department ◽

Acute Heart Failure ◽

Follow Up Study

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Health care provided to recent asylum-seeking and non-asylum-seeking pediatric patients in 2016 and 2017 at a Swiss tertiary hospital - a retrospective study

BMC Public Health ◽

10.1186/s12889-020-10082-z ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Julia Brandenberger ◽

Christian Pohl ◽

Florian Vogt ◽

Thorkild Tylleskär ◽

Nicole Ritz

Keyword(s):

Health Care ◽

Emergency Department ◽

Retrospective Study ◽

Hospital Admissions ◽

Tertiary Care ◽

Tertiary Hospital ◽

Care Hospital ◽

Children With Medical Complexity ◽

Cross Sectional ◽

Number Of Visits

Abstract Background Asylum-seeking children represent an increasing and vulnerable group of patients whose health needs are largely unmet. Data on the health care provision to asylum-seeking children in European contexts is scarce. In this study we compare the health care provided to recent asylum-seeking and non-asylum-seeking children at a Swiss tertiary hospital. Methods We performed a cross-sectional retrospective study in a pediatric tertiary care hospital in Basel, Switzerland. All patients and visits from January 2016 to December 2017 were identified, using administrative and medical electronic health records. The asylum-seeking status was systematically assessed and the patients were allocated accordingly in the two study groups. Results A total of 202,316 visits by 55,789 patients were included, of which asylum-seeking patients accounted for 1674 (1%) visits by 439 (1%) individuals. The emergency department recorded the highest number of visits in both groups with a lower proportion in asylum-seeking compared to non-asylum-seeking children: 19% (317/1674) and 32% (64,315/200,642) respectively. The median number of visits per patient was 1 (IQR 1–2) in the asylum-seeking and 2 (IQR 1–4) in the non-asylum-seeking children. Hospital admissions were more common in asylum-seeking compared to non-asylum-seeking patients with 11% (184/1674) and 7% (14,692/200,642). Frequent visits (> 15 visits per patient) accounted for 48% (807/1674) of total visits in asylum-seeking and 25% (49,886/200,642) of total visits in non-asylum-seeking patients. Conclusions Hospital visits by asylum-seeking children represented a small proportion of all visits. The emergency department had the highest number of visits in all patients but was less frequently used by asylum-seeking children. Frequent care suggests that asylum-seeking patients also present with more complex diseases. Further studies are needed, focusing on asylum-seeking children with medical complexity.

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Health care provided to asylum-seeking and non-asylum-seeking paediatric patients at a Swiss tertiary hospital

10.21203/rs.2.19022/v1 ◽

2019 ◽

Author(s):

Julia Regina Brandenberger ◽

Christian Pohl ◽

Florian Vogt ◽

Thorkild Tylleskär ◽

Nicole Ritz

Keyword(s):

Health Care ◽

Emergency Department ◽

Hospital Admissions ◽

Tertiary Care ◽

Tertiary Hospital ◽

Cross Sectional Study ◽

Care Hospital ◽

Cross Sectional ◽

Admission Rates ◽

Number Of Visits

Abstract Background & Methods To compare health care provided to asylum-seeking and non-asylum-seeking children, we performed a cross-sectional study in a paediatric tertiary care hospital in Switzerland. Patients were identified using administrative and medical electronic health records from January 2016 - December 2017. Results A total of 202’316 visits by 55’789 patients were included, of which asylum-seeking patients accounted for 1674 (1%) visits by 439 (1%) patients. The emergency department had the highest number of visits in both groups with a lower proportion in asylum-seeking compared to non-asylum-seeking children: 19% (317/1674) and 32% (64’315/200’642) respectively. Hospital admissions were more common in asylum-seeking patients 11% (184/1674) and 7% (14’692/200’642). Frequent visits accounted for 48% (807/1674) of total visits in asylum-seeking and 25% (49’886/200’642) of total visits in non-asylum-seeking patients. Conclusions Hospital visits by asylum-seeking children represented a small proportion of all visits. The emergency department had the highest number of visits in all patients and was less frequently used in asylum-seeking children. Higher admission rates and a larger proportion of visits from frequently visiting patients suggest that asylum-seeking patients may present with more complex diseases.

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