Resumen



Original article



261-9



August
2023
261
269

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Decisions to admit vs. discharge patients with acute heart failure from the emergency department: consistency with a measure of severity of decompensation and the impact on prognosis




Miró O, Llorens P, Gil V, López Díez MP, Jacob J, Herrero P, Llauger L, Tost J, Aguirre A, Bibiano C, Fuentes M, López Grima ML, Romero R, Martín Mojarro E, Alquézar Arbé A, Alonso H, Martín-Sánchez FJ



Área de Urgencias, Hospital Clínic, IDIBAPS, Universitat de Barcelona, Spain. Servicio de Urgencias, Corta Estancia y Hospitalización a Domicilio, Hospital General de Alicante, Instituto de Investigación Sanitaria y Biómedica de Alicante (ISABIAL), Universidad Miguel Hernández, Alicante, Spain. Servicio de Urgencias, Hospital Universitario de Burgos, Burgos, Spain. Servicio de Urgencias, Hospital Universitari de Bellvitge, l’Hospitalet de Llobregat, Barcelona, Spain. Servicio de Urgencias, Hospital Universitario Central de Asturias, Oviedo, Spain. Servicio de Urgencias, Hospital Universitari de Vic, Barcelona, Spain. Servicio de Urgencias, Consorci Hospitalari de Terrassa, Barcelona, Spain. Servicio de Urgencias, Hospital del Mar, Barcelona, Spain. Servicio de Urgencias, Hospital Infanta Leonor, Madrid, Spain. Servicio de Urgencias, Hospital Universitario de Salamanca, Salamanca, Spain. Servicio de Urgencias, Hospital Dr. Peset, Valencia, Spain. Servicio de Urgencias, Hospital de Getafe, Universidad Europea, Madrid, Spain. Servicio de Urgencias, Hospital Sant Pau i Santa Tecla, Tarragona, Spain. Servicio de Urgencias, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain. Servicio de Urgencias, Hospital Marqués de Valdecilla, Santander, Spain. Servicio de Urgencias, Hospital Clínico San Carlos, Universidad Complutense, IDICSC, Madrid, Spain.



Objectives. To analyze the consistency between decisions to discharge or admit patients with acute heart failure (AHF) treated in emergency departments (EDs) and the level of risk of adverse events, and to analyze the impact of decisions to discharge patients.
Methods. Prospective study of baseline clinical data collected from patients diagnosed with AHF in 16 Spanish emergency departments. Patients were stratified by severity of decompensated AHF based on MEESSI assessment (Multiple Estimation of Risk Based on the Spanish Emergency Department Score). The distribution of severity was described for patients who were hospitalized (overall and for departments receiving the largest number of admissions) and for discharged patients. We analyzed the data for discharged patients for associations with the following quality-of-care indicators: all-cause mortality of less than 2% at 30 days, revisits to the ED for AHF in less than 10% of patients within 7 days of discharge, and revisits to the ED or admission for AHF in less than 20% within 30 days of discharge.
Results. We included 2855 patients with a median (interquartile range) age of 84 (76-88) years. Fifty-four percent were women, 1042 (36.5%) were classified as low risk, 1239 (43.4%) as intermediate risk, 301 (10.5%) as high risk, and 273 (9.6%) as very high risk. Thirty-day mortality rates by level of low to very high risk were 1.9%, 9.3%, 15.3%, and 38.4%, respectively. One-year mortality rates by risk level were 15.4%, 35.6%, 52.0%, and 74.2%. Admission rates by risk level were 62.2%, 77.4%, 87.0%, and 88.3%. Overall, 47.1% o patients discharged from the ED were in the 3 higher-risk categories (intermediate to very high), and 30.7% were in the lowest risk category. The 5 hospital areas receiving the most admissions, in order of lowest-to-highest risk classification, were internal medicine, the short-stay unit, cardiology, intensive care, and geriatrics. Rates and 95% CIs for quality-of-care indicators in patients discharged from EDs were as follows: 30-day mortality, 4.3% (3.0%-6.1%); ED revisits within 7 days, 11.4% (9.2%-14.0%), and ED
revisits or admissions within 30 days, 31.5% (28.0%-35.1%). In patients classified as low risk on ED discharge, these percentages were lower, as follows, respectively: 0.5% (0.1%-1.8%), 10.5% (7.6%-14.0%), and 29.5% (26.6%-32.6%).
Conclusions. We detected disparity between severity of AHF decompensation and the decision to discharge or admit patients. Outcomes in patients discharged from EDs do not reach the recommended quality-of-care standards. Reducing inconsistencies between severity of decompensation and ED decisions could help to improve quality targets.


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