Europeans Issue Guidance on Direct Discharge of Acute Heart Failure Patients From ED

Select patients presenting with acute heart failure can be safely discharged from the emergency department (ED), but only after determination of the precipitating causes, risk stratification, and assessment of treatment responses, according to new position paper from a European Society of Cardiology (ESC) study group.

The authors focus on the important role of observation units in allowing patients to go home without being admitted and emphasize the need for careful follow-up regardless of whether patients are discharged directly from the ED or after a hospital admission.

“Ultimately, successful strategies to safely avoid hospitalization could have a major impact, not only on the quality of life for heart failure patients, but also on societal costs,” they write in the paper published online this week ahead of print in European Heart Journal: Acute Cardiovascular Care.

The document represents the first European guidance on emergency care for patients with acute heart failure, for whom there are no established treatment pathways like those that have been used for MI for decades, said Christian Mueller, MD, of University Hospital Basel (Basel, Switzerland) and chair of the Acute Heart Failure Study Group of the ESC Acute Cardiovascular Care Association, in a press release.

The position paper “is the first step towards catching up with heart attack care and establishing similar standards for acute heart failure,” Mueller said.

Unnecessary hospital admissions can lead to excess costs and hospital-related complications, whereas inappropriate discharges from the ED can place patients at risk for poor outcomes. But because there is a lack of clear guidance on discharging from the ED, emergency physicians tend to err on the side of caution and admit most patients with acute heart failure.

“This is because, after a discharge decision, there is no second opinion, no ability to evaluate treatment response, and no capability to intervene in a less than optimal social situation,” the authors write. “In this setting, a wrong ‘discharge-home’ decision may actually harm the patient and discharges without due consideration are also a potential litigation risk.”

To help in the decision about where patients should go after leaving the ED, whether it is the intensive care unit, a general hospital ward, or home, the guidance contains an algorithm.

One of the key components of the initial patient assessment that starts the decision-making process is the identification of the cause of the acute episode. “For example, while dietary indiscretion may be easily treated by a temporary increase in diuretics and ED discharge, a concomitant acute coronary syndrome, pulmonary infection, or arrhythmia will need hospital admission,” the authors write.

Another crucial step is risk stratification, which “is not currently performed in most EDs, essentially because of the lack of proper and validated tools, and the absence of a clear definition of what a low risk means for [acute heart failure] patients in terms of mortality, rehospitalization, and ED reconsultation,” they note, adding that those issues need to worked out in future studies.

Observation Period a Must

Patient risk stratification can be performed during an observation period in the ED, with some hospitals using a dedicated observation unit. Such a unit “may represent a good destination for the less sick patient to check clinical improvement, obtain cardiologist advice, receive proper education and instruction, and have their postdischarge appointments arranged, thereby allowing direct discharge without hospitalization,” according to the authors.

When this kind of observation approach is not available, however, “admission of practically all patients with [acute heart failure] will be the rule,” they say. Hospitalization is also mandatory for patients having their first episode of heart failure, the guidance states.

After the decision has been made to send a patient home from the ED, treating physicians “must assure that even though the patient is at low risk, a minimum number of clinical precautions should be enacted before discharging, including factors that encourage successful patient self-management,” the authors write. Those factors include the presence of a partner or other caregiver, a supply of medication, arrangements for follow-up visits, and advice about when to seek additional help.

If barriers to self-care are identified, they add, the patient—even if deemed low risk—should be admitted.

Source: 
Miró Ò, Peacock FW, McMurray JJ, et al. European Society of Cardiology-Acute Cardiovascular Care Association position paper on safe discharge of acute heart failure patients from the emergency department. Eur Heart J Acute Cardiovasc Care. 2016;Epub ahead of print.

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