Emergency department observation of heart failure is safe and cost-effective

Abstract

Supported by a grant from the Emergency Medicine Foundation. Study objectives: We determine whether emergency department (ED)–based observation unit treatment of patients with heart failure can reduce inpatient admissions, hospital bed-hours, and costs without adversely affecting outcomes. Methods: Two groups of risk-matched patients with acute decompensation of chronic heart failure were compared: (1) patients admitted before the availability of our observation unit; and (2) patients admitted to the observation unit after it was opened. Patients were enrolled if they satisfied Framingham criteria modified to include variables available in the ED. Patients believed to be at high risk or with new-onset heart failure were excluded. Outcomes were readmissions or repeated ED visits for heart failure and death. We compared crude estimates of bed-hours and charges between the groups. Results: Sixty-four patients were enrolled, 36 admitted patients and 28 observation unit patients. Use of the observation unit avoided admission in more than 78.6% of cases; 22 observation unit patients who would have been admitted in the absence of an observation unit were not. No patients died within 30 days; 10 were readmitted. There was no difference in event rates between admitted patients (6 events, 16.7%) and observation unit patients (4 events, 14.3%; difference 2.4%, 95% confidence interval [CI] −16.9 to 19.9). Time from triage to discharge was significantly shorter for observation unit patients (median 25.7 hours, range 9.5 to 108.6) compared with admitted patients (median 58.5 hours, range 11.5 to 173.0); the mean number of bed-hours saved through observation unit use was 43.2 hours (95% CI 26 to 60.4 hours). Total charges were lower for observation unit patients (median $4,203, range $2,518 to $17,485) compared with admitted patients (median $7,824, range $3,730 to $34,604). The mean cost difference was $3,753 (95% CI $830 to $6,676), with the great majority of this difference accounted for by inpatient charges. Conclusion: This pilot trial suggests that our subset of admitted heart failure patients may be safely and cost-effectively treated in an ED-based observation unit.