Review ArticleHeart Failure Observation Units: Optimizing Care
Introduction
Heart failure causes substantial morbidity and mortality in the United States and is the most common principal discharge diagnosis in the Medicare population (adults ≥65 years of age).1, 2 Among patients hospitalized with heart failure, almost 80% are receiving Medicare benefits,3 and Medicare pays more money for patients with heart failure than for patients with myocardial infarction or any single cancer.1 Altogether, the costs for heart failure hospitalizations equal approximately $14.7 billion per year.4 Because outpatient costs are estimated to equal this number, the total economic burden of heart failure exceeds $28 billion annually.
Selected patients can receive care for acute decompensated heart failure in special heart failure observation units. Placement in these units provides a safe and effective alternative to hospitalization and offers a feasible strategy for lowering the costs associated with heart failure care.5 Recent reports suggest that observation unit management provides significant benefits for patients and institutions, including reductions in the incidence of overall hospitalization, hospital readmissions, ICU admissions, and subsequent heart failure observation unit visits, as well as hospital length of stay and, ultimately, health care costs.6, 7, 8, 9 In one evaluation, institution of an observation unit treatment protocol for heart failure was associated with a 56% reduction in the 90-day heart failure emergency department (ED) revisit rate (P<.0001) and a 64% reduction in the 90-day heart failure rehospitalization rate (P=.007). Additionally, there was a trend toward a reduction in the 90-day mortality rate, from 4% to 1% (P=.096).6 Furthermore, early and effective heart failure management in the observation unit or ED, often with implementation of detailed treatment protocols, can help reduce the number and severity of complications arising from acute decompensated heart failure.10 This early intervention and avoidance of hospital admission can result in significant cost savings because 75% of costs arising from hospitalization for heart failure are incurred within the first 48 hours.11
This review provides an overview of optimal acute decompensated heart failure management in the observation unit.
Section snippets
Diagnosis
It can be difficult to accurately diagnose heart failure in the ED because many patients presenting with dyspnea and other symptoms of heart failure are elderly and have multiple comorbidities.12 Misdiagnosis rates for heart failure, resulting in both false-positive and false-negative diagnoses, have been reported to be as high as 18.5% in the emergency setting.12, 13, 14
Common cardiac diagnostic tools used in the ED, which are important for correctly assessing acute coronary syndromes and
The Observation Unit in the Emergency Setting
Approximately 1% of ED patients have heart failure.7, 34 The physician in an ED without an observation unit has few options for treating these patients, which results in high rates of hospital admissions when such patients present to the ED. Studies have shown that safe and effective heart failure management strategies in the ED observation unit can decrease the number of ED visits, hospitalizations, and ICU admissions, thus potentially improving quality of life compared with non-observation
Heart Failure Management in the Observation Unit: An Algorithmic Approach
Decompensated heart failure can be a complicated treatment problem. Aggressive heart failure management protocols instituted in the observation unit have led to improved patient outcomes and reduced hospital admission rates.8, 23 Observation unit treatment protocols for patients presenting with acute decompensated heart failure include the implementation of diagnostic and therapeutic algorithms, cardiology department consultations, aggressive nursing monitoring, detailed patient education, and
ACE Inhibitors and β-Blocker Therapy
Long-term heart failure management with ACE inhibitors and β-blocker therapy has been shown to improve survival and disease prognosis.21, 74, 75 Although the use of ACE inhibitors during episodes of acute decompensated heart failure is not as well established as the use of these agents in chronic heart failure management,12 data have demonstrated that ACE inhibitors can reduce pulmonary capillary wedge pressure and improve overall hemodynamic status in patients experiencing acute decompensated
Conclusion
Observation unit strategies for the management of acute decompensated heart failure should result in reductions in hospital admissions and in the costs associated with the care of heart failure patients. Although recent improvements in therapeutic options, including the regular use of ACE inhibitors and β-blockers, have improved the prognosis for many patients with heart failure, episodes of acute decompensated heart failure do occur, requiring therapy that results in rapid symptomatic and
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Supervising editor: W. Brian Gibler, MD
Funding and support: Supported by an unrestricted educational grant from Scios Inc.