Abstract 133: Early Impact of Systematizing the Evaluation of Patients with Heart Failure Presenting to the Emergency Department

Abstract

Introduction: It can be difficult in patients with heart failure (HF) who present to the emergency department (ED) with shortness of breath to decide who warrants admission and who can be safely sent home. At our institution, there was great variability across ED physicians’ admission rates (66%-100%). To address this, we developed an evidence-based protocol to support more consistent HF evaluation in the ED and implemented the program with the help of a multi-disciplinary team. Methods: HF patients presenting to the ED with shortness of breath were eligible for the CODE HF protocol, which was hinged on the use of the prospectively-validated Emergency Heart Failure Mortality Risk Grade (EHMRG) score. Patients with a <1% 7-day mortality were eligible for discharge, if their symptoms improved and the patient and ED physician were comfortable with discharge. The protocol also included HF education in the ED and follow-up. Outcomes included a comparison of patients on and off the CODE HF pathway (1/18-10/18) for ED length of stay, ED discharge, time to outpatient visits among those discharged from the ED and short-stay (potentially unnecessary) hospitalizations. Pearson Chi-square and one-way ANOVA tests were used for comparison. Given our experience that non-patient factors were responsible for not using the protocol, patient-level adjustment was not done. Results: A total of 112 patients out of 933 HF patients seen in the ED between 1/18 and 10/18 were managed through the CODE HF protocol. The EHMRG was calculated in 82 (73%) patients (45 high risk, 37 low risk). When used, the CODE HF protocol was associated with 46% greater rates of ED discharges (14.1% vs 25.9%), a 7-day faster cardiology follow-up visit (25 vs 16 days) and 36% fewer hospital short-stays of <48 hours (12.6% vs 8%) among admitted patients (p<0.05 for all). Importantly, the protocol reduced time in the ED by 42 minutes (288 vs 246 minutes). Conclusions: In this quality improvement pilot study, early implementation of the CODE HF protocol showed more effective care being delivered. A more robust study with wider implementation and evaluation of its impact on return visits is underway.