2 results
LO02: Heart failure and palliative care in the emergency department
- M. Lipinski, D. Eagles, L.M. Fischer, L. Mielneczuk, I.G. Stiell
-
- Journal:
- Canadian Journal of Emergency Medicine / Volume 19 / Issue S1 / May 2017
- Published online by Cambridge University Press:
- 15 May 2017, pp. S27-S28
- Print publication:
- May 2017
-
- Article
-
- You have access Access
- Export citation
-
Introduction: Heart failure (HF) is a common ED presentation that is associated with significant morbidity and mortality. Despite recent evidence and recommendations for early palliative care (PC) involvement in these patients, they are still significantly under-served by PC services, often resulting in multiple ED visits. We sought to evaluate use of PC services in patients with HF presenting to the ED. Secondary objectives of the study were to investigate: 1) one year mortality, ED visits, and admissions; 2) application of a novel palliative care referral score. Methods: We conducted a health records review of 500 consecutive HF patients who presented to two academic hospital EDs. We included patients aged 65 years or older who were diagnosed as having a HF exacerbation by the emergency physician (ICD-10 code 150.-). Our primary outcome was PC involvement. Secondary outcomes included one year mortality rates, ED visits, admissions to hospital, as well as the application of a novel PC referral score developed by the institutional cardiac Palliative Care Committee. The score consisted of 6 different aspects of the patient’s illness, including laboratory tests, hospital usage, and markers of decompensation. We conducted appropriate univariate analyses. Results: Patients were mean age 80.7 years, women (53.2%), and had significant comorbidities (atrial fibrillation (51.2%), diabetes (40.4%) and COPD (20.8%)). Compared to those with no PC, the 79 (15.8%) patients with PC involvement had a higher one year mortality rate (70.9% vs. 18.8%, p<0.0001), more ED visits/year for HF (0.82 vs. 0.52, p<0.0001), and more hospital admissions/year for HF (1.4 vs. 0.85, p<0.0001). Using the heart failure palliative care score criteria, 60 patients had scores >=2. Compared to those with scores <2, these patients had a higher 1-year mortality rate (50% vs. 24%, p<0.0001) and more ED visits/year for HF (0.83 vs. 0.54, p<0.01). Only 40.0% of these high risk patients had any PC involvement. Conclusion: We found that few HF patients had PC services involved in their care. Using this novel HF palliative care referral score, we were able to identify patients with a significantly greater risk of mortality and morbidity. This study provides evidence that the ED is an appropriate setting to identify and refer high risk HF patients who would likely benefit from earlier PC involvement and may be a future avenue for PC access for these patients.
PL01: Creation of the Canadian Heart Failure Risk Scale for acute heart failure patients
- I.G. Stiell, C.M. Clement, J.J. Perry, R.J. Brison, A. McRae, B.H. Rowe, B. Borgundvaag, S. Aaron, L. Mielneczuk, L. Calder, J. Brinkhurst, A. Forster, G.A. Wells
-
- Journal:
- Canadian Journal of Emergency Medicine / Volume 19 / Issue S1 / May 2017
- Published online by Cambridge University Press:
- 15 May 2017, p. S26
- Print publication:
- May 2017
-
- Article
-
- You have access Access
- Export citation
-
Introduction: Acute heart failure (AHF) is a common, serious condition that frequently results in morbidity and death and is a leading cause for hospital admissions. There is little evidence to guide ED physician disposition decisions for AHF patients. We sought to create a risk-stratification tool for use by ED physicians to determine which AHF patients are at high risk for poor outcomes. Methods: We conducted a prospective cohort study in 9 tertiary hospital EDs and enrolled adult patients presenting with shortness of breath due to AHF. Patients were assessed for standardized clinical and laboratory variables and then followed to determine short-term serious outcome (SSO), defined as death, intubation, myocardial infarction, or relapse requiring admission within 14 days. We identified predictors of SSO by stepwise logistic regression and then rounded beta coefficients to create a risk scale. Results: We enrolled 1,733 patients with mean age 77.1 years, male 54.5%, and initially admitted 50.1%. SSOs occurred in 202 (11.7%) cases (14.0% in those admitted and 9.3% in those discharged from the ED). We created the CHFRS consisting of:1. Initial Assessment a) History of valvular heart disease b) On anti-arrhythmic c) Arrival heart rate ≥ 110d) Treated with non-invasive ventilation2. Investigations a) Urea >12 mmol/L or Cr>150 µmol/L b) Serum CO2>35 mmol/L or pCO2 >60 mmHg (VBG or ABG) c) Troponin >5x Upper Reference Level 3. Fails reassessment after ED treatment:(i) Resting vital signs abnormal, (SaO2 <90% on room air or usual O2, or HR >110, or RR >28); OR(ii) Unable to complete 3-minute walk test. The risk of SSO varied from 5.0% for a score of 0, to 77.4% for a score of 9. Discrimination between SSO and no SSO cases was good with an area under the ROC curve of 0.70 (95% CI 0.66-0.74). There was good calibration between the observed and expected probability of SSO and internal validation showed the risk scores to be very accurate across 1,000 replications using the bootstrap method. Conclusion: We have created the CHFRS tool which consists of 8 simple variables and which estimates the short-term risk of SSOs in AHF patients. CHFRS should help improve and standardize admission practices, diminishing both unnecessary admissions for low-risk patients and unsafe discharge decisions for high-risk patients. This will ultimately lead to better safety for patients and more efficient use of hospital resources.
![](/core/cambridge-core/public/images/lazy-loader.gif)