EDMONTON, Alberta -- October 29, 2009 -- Patients with heart failure who are discharged from the emergency room (ER) have a substantially increased risk of early death compared with those who are admitted -- even among patients with comparable degrees of heart failure, according to researchers at the 2009 Canadian Cardiovascular Congress (CCC).
An analysis of medical records from more than 50,000 heart-failure patients demonstrated that the 90-day mortality among patients was almost a third higher (12.4% vs 9.4%) for those discharged from the ER compared with those admitted to hospital (P < .001). The data were presented here on October 26.
"The rates of early death among those who are not admitted to hospital exceeds that of hospitalised patients with comparable predictive mortality risk -- suggesting that we may need better algorithms for evaluating patients in the emergency department," reported Douglas S. Lee, MD, PhD, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
Some of the variables characterising those more likely to be admitted -- such as a high triage acuity score or older age -- make sense, Dr. Lee noted, but others, such as arrival by ambulance or resuscitation in the ER, appear to be more driven by a subjective sense of disease severity.
Over a 3-year period (April 2004 through March 2007), 50,816 patients in the province of Ontario, Canada, visited an emergency department because of heart failure. Of these patients, 16,094 (31.7%) were discharged without hospital admission. The odds ratio (OR) for being admitted increased by 8% for each decade of life but doubled (OR = 2.02) if the patient arrived by ambulance and almost tripled (OR = 2.85) if an emergency-room resuscitation was administered. A high triage acuity score increased the likelihood of admission by more than 4 fold (OR = 4.12).
The mortality risk in the discharged patients was significantly increased at 90 days whether patients were stratified by predicted likelihood of mortality over 7 days or over 30 days.
These data are potentially important, because this is an issue that has not been well studied previously, Dr. Lee noted. Given the important differences in outcome for those discharged in this study, the current decision-making process about when to admit patients and when to allow them to return home appears to be suboptimal.
Although this was an observational study, Dr. Lee suggested that studies to formalise and improve algorithms for admitting or discharging heart-failure patients presenting in the ER appear to be needed.
CCC is co-hosted by the Canadian Cardiovascular Society and the Heart and Stroke Foundation of Canada.
[Presentation title: Population-Based Evaluation of Mortality of Heart Failure Patients Discharged From the Emergency Department. Abstract 556]
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