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Emergency department observation of patients with acute heart failure prior to hospital admission: impact on short-term prognosis

López Díez MP, Llorens P, Martín-Sánchez FJ, Gil V, Jacob J, Herrero P, Llauger L, Tost J, Aguirre A, Garrido JM, Vega JA, Fuentes M, Alonso MI, López Grima ML, Piñera P, Romero R, Lucas-Imbernón FJ, Andueza JA, Povar J , Richard F, Sánchez C, Miró O

Emergency department, Hospital Universitario de Burgos, Burgos, Spain. Emergency department, Short stay and Home Hospitalization, Hospital General de Alicante, Instituto de Investigación Sanitaria y Biómedica de Alicante (ISABIAL), Universidad Miguel Hernández, Alicante, Spain. Emergency department, Hospital Clínico San Carlos, Universidad Complutense, Madrid, Spain. Emergency department, Hospital Clínic, IDIBAPS, Universitat de Barcelona, Spain. Emergency department, Hospital Universitari de Bellvitge, l’Hospitalet de Llobregat, Barcelona, Spain. 6Emergency Department, Hospital Universitario Central de Asturias, Oviedo, Spain. Emergency Department, Hospital Universitari de Vic, Barcelona, Spain. Emergency Department, Consorci Hospitalari de Terrassa, Barcelona, Spain. Emergency Department, Hospital del Mar, Barcelona, Spain. Emergency Department, Hospital Virgen de la Macarena, Sevilla, Spain. Emergency Department, Hospital Universitario Reina Sofia, Cordoba, Spain. Emergency Department, Hospital Universitario de Salamanca, Salamanca, Spain. Emergency Department, Hospital Valme, Sevilla, Sevilla, Spain, Sevilla, Spain. Emergency Department, Hospital Dr. Peset, Valencia, Spain. Emergency Department, Hospital Universitario Reina Sofía, Murcia, Spain. Emergency Department, Hospital Universitario de Getafe, Universidad Europea, Spain. de Getafe, Universidad Europea, Madrid, Spain. Emergency Department, Hospital Universitario de Albacete, Albacete, Spain. Emergency Department, Hospital Universitario Dr. Gregorio Marañón, Madrid, Spain. Marañón, Madrid, Spain. Emergency Department, Miguel Servet University Hospital, Zaragoza, Spain.

Objectives. To analyze whether short-term outcomes are affected when patients diagnosed with acute heart failure (AHF) spend time in an emergency department observation unit (EDOU) before hospital admission.
Methods. Baseline and emergency episode data were collected for patients diagnosed with AHF in the EDs of 15 Spanish hospitals. We analyzed crude and adjusted associations between EDOU stay and 30-day mortality (primary outcome) and in-hospital mortality and a prolonged hospital stay of more than 7 days (secondary outcomes).
Results. A total of 6597 patients with a median (interquartile range) age of 83 (76-88 years) were studied. Fifty-five percent were women. All were hospitalized for AHF (50% in internal medicine wards, 23% in cardiology, 11% in geriatrics, and 16 in other specialties. Of these patients, 3241 (49%) had had EDOU stays and 3350 (51%) had been
admitted immediately, with no EDOU stay. Having an EDOU stay was associated with female sex, dementia or chronic obstructive pulmonary disease, long-term treatment with certain drugs for heart failure, greater baseline deterioration in function, and a higher degree of decompensation. Patients in the EDOU group were more often admitted to an
internal medicine ward and had shorter stays; cardiology, geriatric, and intensive care admissions were less likely to have had an EDOU stay. Overall, 30-day mortality was 12.6% (13.7% in the EDOU group and 11.4% in the no-EDOU group; P = .004). In-hospital mortality was 10.4% overall (EDOU, 11.1% and no-EDOU, 9.6%; P = .044). Prolonged
hospitalization occurred in 50.0% (EDOU, 48.7% and no-EDOU, 51.2%; P = .046). After adjusting for between-group differences, the EDOU stay was not associated with 30-day mortality (hazard ratio, 1.14; 95% CI, 0.99-1.31). Odds ratios for associations between EDOU stay and in-hospital mortality and prolonged hospital stay, respectively, were
1.09 (95% CI, 0.92-1.29) and 0.91 (95% CI, 0.82-1.01).
Conclusion. Although mortality higher in patients hospitalized for AHF who spend time in an EDO, the association seems to be accounted for by their worse baseline situation and the greater seriousness of the decompensation episode, not by time spent in the EDOU.

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