Abstract 35: Developing a Systematic Process for Evaluating Heart Failure (HF) Patients Presenting to the Emergency Department: The Code HF Project

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 different ED physician’s admission rates (66%-100%). To address this, we developed an evidence-based protocol to support more consistent evaluation and implemented the program with the help of a multi-disciplinary team. Here, we discuss the process of development. Methods: An ED physician led a team of cardiologists, nurses, educators, administrators and researchers to identify key considerations in the ED management of patients with HF and to create a feasible protocol for implementation (Figure). A central feature of this approach is the use of a prospectively validated Emergency Heart Failure Mortality Risk Grade (EHMRG) score and agreement that patients with a <1% 7-day mortality would be eligible for discharge if their symptoms rapidly improved and close follow up could be arranged. Iterative improvements to the protocol and its execution with the electronic medical record (EMR) were made to improve our primary process measure, use in all eligible patients. Results: Despite education at provider meetings and integration within the EMR, over the first year of implementation across all four EDs within the network, only 12% of eligible patients were managed by Code HF, with marked variability across EDs (0-20% of eligible patients) and physicians (0-80%). Further opportunities to improve adoption were elicited from providers and included different presentations within the EMR, creation of a standing order, integration of the predicted risk into ED notes and regular feedback of use and outcomes associated with the Code HF program. Conclusion: Implementing an evidence-based, sustainable strategy for systematically evaluating and managing patients with HF presenting to the ED has been challenging, but offers the opportunity to deliver more efficient, patient-centered care. Iterative improvements informed by providers and tailored to our local context is leading to increased protocol use among ED physicians.