Care setting intensity and outcomes after emergency department presentation among patients with acute heart failure

Goldraich L, Austin PC, Zhou L, Tu JV, Schull MJ, Mak S, Ross HJ, Morrow DA, Lee DS. J Am Heart Assoc. 2016; 5:e003232.

Background — Patients with heart failure (HF) presenting to the emergency department (ED) can be admitted to care settings of different intensity, where the intensive care unit (ICU) is the highest intensity, ward admission is intermediate intensity, and those discharged home are of lowest intensity. Despite the costs associated with higher‐intensity care, little is known about disposition decisions and outcomes of HF patients treated in different care settings.

Methods and Results — We identified predictors of ICU or ward admission and determined whether survival differs in patients admitted to higher‐intensity versus lower‐intensity care settings (ie, ICU vs ward, or ward vs ED‐discharged). Among 9054 patients (median, 78 years; 51% men) presenting to an ED in Ontario, Canada, 1163 were ICU‐admitted, 5240 ward‐admitted, and 2651 were ED‐discharged. Predictors of ICU (vs ward) admission included: use of noninvasive positive pressure ventilation (adjusted odds ratio [OR], 2.01; 95% CI, 1.36–2.98), higher respiratory rate (OR, 1.10 per 5 breaths/min; 95% CI, 1.05–1.15), and lower oxygen saturation (OR, 0.90 per 5%; 95% CI, 0.86–0.94; all P<0.001). Predictors of ward‐admitted versus ED‐discharged were similar. Propensity‐matched analysis comparing lower‐risk ICU to ward‐admitted patients demonstrated a nonsignificant trend at 100 days (relative risk [RR], 0.69; 95% CI, 0.43–1.10; P=0.148). At 1 year, however, survival was higher among those initially admitted to ICU (RR, 0.68; 95% CI, 0.49–0.94; P=0.022). There was no survival difference among low‐risk ward‐admitted versus ED‐discharged patients.

Conclusions — Respiratory factors were associated with admission to higher‐intensity settings. There was no difference in early survival between some lower‐risk patients admitted to higher‐intensity units compared to those treated in lower‐intensity settings.

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Keywords: Emergency department visits Risk assessment Intensive/critical care Health care quality