Impact of Systematizing the Evaluation of Patients with Acute Heart Failure Presenting to the Emergency Department
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The huge burden of acute heart failure (HF) on the emergency department (ED) warrants the need for a systemized method of management. The lack of a standardized care path for acute HF patients presenting to the ED has resulted in wide variability in care and high hospital admission rates. An evidence-based, patient-centered clinical decision support pathway implemented within the ED, can systematize the management of acute HF and tailor management to patients’ needs. From January 2017 to February 2020, using an implementation planning framework, a standardized care path called the ‘Code Heart Failure’ (CodeHF) was developed, implemented, and validated within a tertiary care center. The care path rapidly identifies patients with a history of HF presenting to the ED with a chief complaint of shortness of breath and uses an evidence-based risk stratification tool to identify those who are eligible for discharge. Outcomes of acute HF patients who were treated by the CodeHF pathway were compared to those treated through usual care. The completeness of implementation was assessed by the proportion of eligible patients treated using the CodeHF pathway. The pathway’s impact on processes of care was evaluated by admission/discharge time in the ED and the proportion of discharged patients seen in cardiology clinic within 7 days. The primary outcome was the proportion of ED discharges, with safety and efficiency assessed by 30-day readmission rates after ED discharge and the proportion of short hospitalizations (<48 hours). Among 1100 eligible patients (mean [SD] age, 72.3 [15.2] years; 48.7% male), 149 (13.5%) were managed using CodeHF, with wide physician-level variability. Of those on the pathway, 74 (49.6%) had a high, and 75 (50.3%) a low, risk of 7-day mortality. CodeHF was associated with 54 minutes (294 vs 240 minutes) less time in the ED and a greater proportion of patients with a cardiology clinic visit within 7 days of ED discharge (25.9% vs 50%). Use of the pathway was associated with a greater rate of ED discharge (37.9% vs. 25.2%) and fewer 30-day readmissions after ED discharge (16.0% vs. 21.3%) and short inpatient stays (9.0% vs. 11.4%). In this detailed report, I describe the need, process of development, implementation, and validation of the CodeHF program which is an evidence-based clinical decision support tool used to systemize the management of acute HF in the ED.
Table of Contents
Introduction -- Review of literature -- Methodology -- Results -- Discussion -- Appendix
M.S. (Masters of Science)