To determine the impact of risk stratification using the MEESSI-AHF (Multiple Estimation of risk based on the Emergency department Spanish Score In patients with acute heart failure) scale to guide ...disposition decision-making on the outcomes of ED patients with acute heart failure (AHF), and assess the adherence of emergency physicians to risk stratification recommendations.
This was a prospective quasi-experimental study (before/after design) conducted in eight Spanish EDs which consecutively enrolled adult patients with AHF. In the pre-implementation stage, the admit/discharge decision was performed entirely based on emergency physician judgement. During the post-implementation phase, emergency physicians were advised to 'discharge' patients classified by the MEESSI-AHF scale as low risk and 'admit' patients classified as increased risk. Nonetheless, the final decision was left to treating emergency physicians. The primary outcome was 30-day all-cause mortality. Secondary outcomes were days alive and out of hospital, in-hospital mortality and 30-day post-discharge combined adverse event (ED revisit, hospitalisation or death).
The pre-implementation and post-implementation cohorts included 1589 and 1575 patients, respectively (median age 85 years, 56% females) with similar characteristics, and 30-day all-cause mortality was 9.4% and 9.7%, respectively (post-implementation HR=1.03, 95% CI=0.82 to 1.29). There were no differences in secondary outcomes or in the percentage of patients entirely managed in the ED without hospitalisation (direct discharge from the ED, 23.5% vs 24.4%, OR=1.05, 95% CI=0.89 to 1.24). Adjusted models did not change these results. Emergency physicians followed the MEESSI-AHF-based recommendation on patient disposition in 70.9% of cases (recommendation over-ruling: 29.1%). Physicians were more likely to over-rule the recommendation when 'discharge' was recommended (56.4%; main reason: need for hospitalisation for a second diagnosis) than when 'admit' was recommended (12.8%; main reason: no appreciation of severity of AHF decompensation by emergency physician), with an OR for over-ruling the 'discharge' compared with the 'admit' recommendation of 8.78 (95% CI=6.84 to 11.3).
Implementing the MEESSI-AHF risk stratification tool in the ED to guide disposition decision-making did not improve patient outcomes.
The Multiple Estimation of Risk Based on the Emergency Department Spanish Score in Patients With Acute Heart Failure (MEESSI-AHF) is a validated clinical decision tool that characterizes risk of ...mortality in emergency department (ED) acute heart failure patients. The objective of this study is to compare the distribution of risk categories between hospitalized and discharged ED patients with acute heart failure.
We included consecutive acute heart failure patients from 34 Spanish EDs. Patients were retrospectively classified according to MEESSI-AHF risk categories. We calculated the odds of hospitalization (versus direct discharge from the ED) across MEESSI-AHF risk categories. Next, we assessed the following 30-day postdischarge outcomes: ED revisit, hospitalization, death, and their combination. We used Cox hazards models to determine the adjusted association between ED disposition decision and the outcomes among patients who were stratified into low- and increased-risk categories.
We included 7,930 patients (80.5 years SD 10.1 years; women 54.7%; hospitalized 75.3%). Compared with that for low-risk MEESSI-AHF patients, odds ratios for hospitalization of patients in intermediate-, high-, and very-high-risk categories were 1.83 (95% confidence interval CI 1.64 to 2.05), 3.05 (95% CI 2.48 to 3.76), and 3.98 (95% CI 3.13 to 5.05), respectively. However, almost half (47.6%) of all discharged patients were categorized as being at increased risk by MEESSI-AHF, and 19.0% of all the increased-risk patients were discharged from the ED. Among the low-risk MEESSI-AHF patients, the 30-day postdischarge mortality did not differ by ED disposition (hazard ratio HR for discharged patients with respect to hospitalized ones 0.65; 95% CI 0.70 to 1.11), nor did it differ in the increased-risk group (HR 0.88; 95% CI 0.63 to 1.23). The discharged low-risk MEESSI-AHF patients had higher risks of 30-day ED revisit and hospitalization (HR 1.86, 95% CI 1.57 to 2.20; and HR 1.92, 95% CI 1.54 to 2.40, respectively) compared with the admitted patients, as did the discharged patients in the increased-risk group (HR 1.62, 95% CI 1.39 to 1.89; and HR 1.40, 95% CI 1.16 to 1.68, respectively), with similar results for the combined endpoint.
The disposition decisions made in current clinical practice for ED acute heart failure patients calibrate with MEESSI-AHF risk categories, but nearly half of the patients currently discharged from the ED fall into increased-risk MEESSI-AHF categories.
Deterioration of renal function with respect to baseline during an acute heart failure (AHF) episode is frequent, but impact on outcomes is still a matter of debate.
To investigate the association of ...creatinine deterioration detected at emergency department (ED) arrival and short-term outcomes in patients with AHF.
Secondary analysis of a large multipurpose registry.
Patients with AHF were diagnosed in 10 Spanish ED for whom a previous baseline creatinine was available.
Difference between creatinine at ED arrival and at baseline was calculated (∂-creatinine).
Primary outcome was 30-day all-cause death, and secondary outcomes were inhospital all-cause death, prolonged hospitalization (>7 days) and 7-day postdischarge adverse events. Associations between ∂-creatinine and outcomes were explored using logistic regression by restricted cubic spline (RCS) curves and expressed as odds ratio (OR) with 95% confidence interval (CI), taking ∂-creatinine = 0 mg/dl as reference. Curves were adjusted by age, sex, comorbidities, patient baseline status, chronic treatments, and vitals and laboratory results at ED arrival. Interactions for the primary outcome also were investigated.
We analyzed 3036 patients (median age = 82 years; IQR = 75-87; women = 55%), with ∂-creatinine ranged from -0.3 to 3 mg/dl. The 30-day mortality was 11.6%. Increments of ∂-creatinine were associated with progressive increase in risk of 30-day death, although adjustment attenuated this association: ∂-creatinine of 0.3/1/2/3 mg/dl were, respectively, associated with adjusted OR of 1.41 (1.02-1.95), 1.69 (1.02-2.80), 1.46 (0.56-3.80) and 1.27 (0.27-5.83). Distinctively significant higher risk was found for patients over 80 years old, female, nondiabetic, functionally disabled and on digoxin therapy. With respect to secondary outcomes, inhospital mortality was 8.1%, prolonged hospitalization was 33.6% and 7-day postdischarge adverse event was 9.7%. Inhospital death steadily increased with increments in ∂-creatinine from 1.50 (1.04-2.17) with ∂-creatinine = 0.3 to 3.78 (0.78-18.3) with ∂-creatinine = 3, as well as prolonged hospitalization did from 1.41 (1.11-1.77) to 2.24 (1.51-3.33), respectively. Postdischarge adverse events were not associated with ∂-creatinine.
WRF detected at ED arrival has prognostic value in AHF, being associated with increased risk of death and prolonged hospitalization. These associations showed different patterns of risk but, remarkably, risk started with increments as low as 0.3 mg/dl.
There is a lack of knowledge about the real incidence of acute coronary syndrome (ACS) in patients with COVID-19, their clinical characteristics, and their prognoses.
We investigated the incidence, ...clinical characteristics, risk factors, and outcomes of ACS in patients with COVID-19 in the emergency department.
We retrospectively reviewed all COVID-19 patients diagnosed with ACS in 62 Spanish emergency departments between March and April 2020 (the first wave of COVID-19). We formed 2 control groups: COVID-19 patients without ACS (control A) and non–COVID-19 patients with ACS (control B). Unadjusted comparisons between cases and control subjects were performed regarding 58 characteristics and outcomes.
We identified 110 patients with ACS in 74,814 patients with COVID-19 attending the ED (1.48% 95% confidence interval {CI} 1.21–1.78%). This incidence was lower than that observed in non–COVID-19 patients (3.64% 95% CI 3.54–3.74%; odds ratio OR 0.40 95% CI 0.33–0.49). The clinical characteristics of patients with COVID-19 associated with a higher risk of presenting ACS were: previous coronary artery disease, age ≥60 years, hypertension, chest pain, raised troponin, and hypoxemia. The need for hospitalization and admission to intensive care and in-hospital mortality were higher in cases than in control group A (adjusted OR aOR 6.36 95% CI 1.84–22.1, aOR 4.63 95% CI 1.88–11.4, and aOR 2.46 95% CI 1.15–5.25). When comparing cases with control group B, the aOR of admission to intensive care was 0.41 (95% CI 0.21–0.80), while the aOR for in-hospital mortality was 5.94 (95% CI 2.84–12.4).
The incidence of ACS in patients with COVID-19 attending the emergency department was low, around 1.48%, but could be increased in some circumstances. Patients with COVID-19 with ACS had a worse prognosis than control subjects with higher in-hospital mortality.
To describe the clinical characteristics of patients with coronavirus disease 2019 (COVID-19) treated in hospital emergency departments (EDs) in Spain, and to assess associations between ...characteristics and outcomes.
Prospective, multicenter, nested-cohort study. Sixty-one EDs included a random sample of all patients diagnosed with COVID-19 between March 1 and April 30, 2020. Demographic and baseline health information, including concomitant conditions; clinical characteristics related to the ED visit and complementary test results; and treatments were recorded throughout the episode in the ED. We calculated crude and adjusted odds ratios for risk of in-hospital death and a composite outcome consisting of the following events: intensive care unit admission, orotracheal intubation or mechanical ventilation, or in-hospital death. The logistic regression models were constructed with 3 groups of independent variables: the demographic and baseline health characteristics, clinical characteristics and complementary test results related to the ED episode, and treatments.
The mean (SD) age of patients was 62 (18) years. Most had high- or low-grade fever, dry cough, dyspnea, and diarrhea. The most common concomitant conditions were cardiovascular diseases, followed by respiratory diseases and cancer. Baseline patient characteristics that showed a direct and independent association with worse outcome (death and the composite outcome) were age and obesity. Clinical variables directly associated with worse outcomes were impaired consciousness and pulmonary crackles; headache was inversely associated with worse outcomes. Complementary test findings that were directly associated with outcomes were bilateral lung infiltrates, lymphopenia, a high platelet count, a D-dimer concentration over 500 mg/dL, and a lactate-dehydrogenase concentration over 250 IU/L in blood.
This profile of the clinical characteristics and comorbidity of patients with COVID-19 treated in EDs helps us predict outcomes and identify cases at risk of exacerbation. The information can facilitate preventive measures and improve outcomes.
To describe the sociodemographic characteristics of and the health care resources used to treat patients aged 65 years or older who come to hospital emergency departments (EDs) in Spain, according to ...age groups.
We studied the phase-1 data for the EDEN cohort (Emergency Department and Elder Needs). Forty Spanish EDs collected data on all patients aged 65 years or older who were treated on the first 7 days in April 2019. We registered information on 6 sociodemographic and 5 function variables for all patients. For health resource use we used 6 diagnostic, 13 therapeutic, and 5 physical structural variables, for a total of 24 variables. Differences were analyzed according to age in blocks of 5 years.
A total of 18 374 patients with a median age of 78 years were included; 55% were women. Twenty-seven percent arrived by ambulance, 71% had not previously been seen by a physician, and 13% lived alone without assistance. Ten percent had a high level of functional dependence, and 14% had serious comorbidity. Resources used most often were blood analysis (in 60%) and radiology (59%), analgesics (25%), intravenous fluids (21%), antibiotics (14%), oxygen (13%), and bronchodilators (11%). Twenty-six percent were kept under observation in the ED, 26% were admitted to wards, and 2% were admitted to intensive care units (ICUs). The median stay in the ED was 3.5 hours, and the median hospital stay was 7 days. Sociodemographic characteristics changed according to age. Functional dependence worsened with age, and resource requirements increased in general. However, benzodiazepine use was unaffected, while the use of nonsteroidal anti-inflammatory drugs and ICU admission decreased.
The functional dependence of older patients coming to EDs increases with age and is associated with a high level of health care resource use, which also increases with age. Planners should take into consideration the characteristics of the older patients and the proportion of the caseload they represent when arranging physical spaces and designing processes for a specific ED.
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.
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.
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%).
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.
To determine the rate of adverse events in patients with acute heart failure (AHF) who were discharged from the emergency department (ED) after classification as low risk according to MEESSI score ...(multiple risk estimate based on the Spanish ED scale), to analyze the ability of the score to predict events, and to explore variables associated with adverse events.
Patients in the EAHFE registry (Epidemiology of Acute Heart Failure in EDs) were stratified according to risk indicated by MEESSI score in order to identify those considered at low risk on discharge. All-cause 30-day mortality and revisits related to AHF within 7 days and 30 days were recorded. The area under the receiver operating characteristic curve (AUC) was calculated for the MEESSI score's ability to predict these events. Associations between 42 variables and 7-day and 30-day revisits to the ED were analyzed by multivariable logistic regression.
A total of 1028 patients were included. The 30-day mortality rate was 1.6% (95% CI, 0.9%-2.5%). The 7-day and 30-day revisit rates were 8.0% (95% CI, 6.4%-9.8%) and 24.7% (95% CI, 22.1%-25.7%), respectively. The AUCs for MEESSI score discrimination between patients with and without these outcomes were as follows: 30-day mortality, 0.69 (95% CI, 0.58-0.80); 7-day revisiting, 0.56 (95% CI, 0.49-0.63); and 30-day revisiting, 0.54 (95% CI, 0.50-0.59). Variables associated with 7-day revisits were long-term diuretic treatment (odds ratio OR, 2.45; 95% CI, 1.01-5.98), hemoglobin concentration less than 110 g/L (OR, 1.68; 95% CI, 1.02-2.75), and intravenous diuretic treatment in the ED (OR, 0.53; 95% CI, 0.31-0.90). Variables associated with 30-day revisits were peripheral artery disease (OR, 1.74; 95% CI, 1.01-3.00), prior history of an AHF episode (OR, 1.42; 95% CI, 1.02-1.98), long-term mineralocorticoid receptor antagonist treatment (OR, 1.71; 95% CI, 1.09-2.67), Barthel index less than 90 points in the ED (OR, 1.48; 95% CI, 1.07-2.06), and intravenous diuretic treatment in the ED (OR, 0.58; 95% CI, 0.40-0.84).
Patients with AHF who are at low risk for adverse events on discharge from our EDs have event rates that are near internationally recommended targets. The MEESSI score, which was designed to predict 30-day mortality, is a poor predictor of 7-day or 30-day revisiting in these low-risk patients. We identified other factors related to these events.
To analyze factors related to the use of digoxin to treat patients with acute heart failure (AHF) in emergency departments (EDs) and the impact of digoxin treatment on short-term outcomes.
We ...included patients diagnosed with AHF in 45 Spanish EDs. The patients, who were not undergoing long-term treatment for heart failure, were classified according to whether or not they were given intravenous digoxin in the ED. Fifty-one patient or cardiac decompensation episode variables were recorded to profile ED patients treated with digoxin. Outcome variables studied were the need for hospital admission, prolonged stay in the ED (> 24 hours) for discharged patients, prolonged hospitalization (> 7 days) for admitted patients, and all-cause in-hospital or 30-day mortality. The associations between digoxin treatment and the outcomes were studied with odds ratios (ORs) adjusted for patient and AHF episode characteristics.
Data for 15 549 patients (median age, 83 years; 55% women) were analyzed; 1430 (9.2%) were treated with digoxin. Digoxin was used more often in women, young patients, and those with better New York Heart Association (NYHA) classifications but more severe cardiac decompensation, especially if the trigger was atrial fibrillation with rapid ventricular response. Admissions were ordered for 75.4% of the patients overall (81.6% of digoxin-treated patients vs 74.8% of nontreated patients; P .001). The ED stay was prolonged in 38.3% of patients discharged from the ED (52.9% of digoxin-treated patients vs 37.2% of nontreated patients; P .001). The duration of hospital stay was prolonged in 48.1% (digoxin-treated, 49.3% vs 47.9%; P = .385). In-hospital mortality was 7.2% overall (6.9% vs 7.2%, P= .712), and 30-day mortality was 9.7% (9.3% vs 9.7%, P = .625). ED use of digoxin was associated with a prolonged stay in the department (adjusted OR, 1.883; 95% CI, 1.359-2.608) but not with hospitalization or mortality.
Digoxin continues to be used in one out of ten ED patients who are not already on long-term treatment with the drug. Digoxin use is associated with cardiac decompensation triggered by atrial fibrillation with rapid ventricular response, younger age, women, and patients with better initial NYHA function status but possibly more severe decompensation. Digoxin use leads to a longer ED stay but is safe, as it is not associated with need for admission, prolonged hospitalization, or short-term mortality.
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