Review Article
Heart Failure Observation Units: Optimizing Care

https://doi.org/10.1016/j.annemergmed.2005.07.006Get rights and content

Heart failure causes substantial morbidity and mortality in the United States and accounts for a higher proportion of Medicare costs than any other disease. Most of these costs result from the high rate of hospital admissions and protracted length of stay associated with episodes of acute decompensation of heart failure. Thus, effective clinical strategies to obviate hospitalization and readmission can result in substantial savings. A specialized heart failure observation unit, in which patients receive rapid, goal-directed emergency care for heart failure symptoms, can be a critical component in this effort, providing intensive therapeutic monitoring and education. In institutions with specialized heart failure observation units, patients are triaged to this setting shortly after presentation to the emergency department (ED), and clinic referrals can be directed to this unit after minimal ED evaluation. Aggressive follow-up is also arranged at discharge. Recent additions to the therapeutic armamentarium and future advances in diagnostics and monitoring will continue to improve patient care and prevent avoidable hospitalizations.

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

References (97)

  • J.E. Rame et al.

    Outcomes after emergency department discharge with a primary diagnosis of heart failure

    Am Heart J

    (2001)
  • M.H. Chin et al.

    Correlates of early hospital readmission or death in patients with congestive heart failure

    Am J Cardiol

    (1997)
  • J. Butler et al.

    Frequency of low-risk hospital admissions for heart failure

    Am J Cardiol

    (1998)
  • M.D. Howell et al.

    Congestive heart failure and outpatient risk of venous thromboembolism: a retrospective, case-control study

    J Clin Epidemiol

    (2001)
  • J.R. Teerlink

    Dyspnea as an end point in clinical trials of therapies for acute decompensated heart failure

    Am Heart J

    (2003)
  • D.E. Forman et al.

    Incidence, predictors at admission, and impact of worsening renal function among patients hospitalized with heart failure

    J Am Coll Cardiol

    (2004)
  • P.R. Marantz et al.

    Clinical diagnosis of congestive heart failure in patients with acute dyspnea

    Chest

    (1990)
  • M.T. Kearney et al.

    Cardiac size, autonomic function, and 5-year follow-up of chronic heart failure patients with severe prolongation of ventricular activation

    J Card Fail

    (2003)
  • V. Cheng et al.

    A rapid bedside test for B-type peptide predicts treatment outcomes in patients admitted for decompensated heart failure: a pilot study

    J Am Coll Cardiol

    (2001)
  • H.M. Krumholz et al.

    Randomized trial of an education and support intervention to prevent readmission of patients with heart failure

    J Am Coll Cardiol

    (2002)
  • J.B. Young et al.

    Superiority of “triple” drug therapy in heart failure: insights from the PROVED and RADIANCE trials

    J Am Coll Cardiol

    (1998)
  • A.J. Burger et al.

    Comparison of the occurrence of ventricular arrhythmias in patients with acutely decompensated congestive heart failure receiving dobutamine versus nesiritide therapy

    Am J Cardiol

    (2001)
  • A.J. Burger et al.

    Effect of nesiritide (B-type natriuretic peptide) and dobutamine on ventricular arrhythmias in the treatment of patients with acutely decompensated congestive heart failure: the PRECEDENT Study

    Am Heart J

    (2002)
  • J.E. Tisdale et al.

    Electrophysiologic and proarrhythmic effects of intravenous inotropic agents

    Prog Cardiovasc Dis

    (1995)
  • C.M. O'Connor et al.

    Continuous intravenous dobutamine is associated with an increased risk of death in patients with advanced heart failure: insights from the Flolan International Randomized Survival Trial (FIRST)

    Am Heart J

    (1999)
  • G.M. Felker et al.

    Heart failure etiology and response to milrinone in decompensated heart failure: results from the OPTIME-CHF study

    J Am Coll Cardiol

    (2003)
  • C.W. Yancy et al.

    Safety and feasibility of using serial infusions of nesiritide for heart failure in an outpatient setting (from the FUSION I Trial)

    Am J Cardiol

    (2004)
  • O.S. Indridason et al.

    Is specialty care associated with improved survival of patients with congestive heart failure?

    Am Heart J

    (2003)
  • M.W. Rich

    Epidemiology, pathophysiology, and etiology of congestive heart failure in older adults

    J Am Geriatr Soc

    (1997)
  • American Heart Association, American Stroke Association. Heart Disease and Stroke Statistics: 2005 Update. Available...
  • W.F. Peacock et al.

    Inpatient versus emergency department observation unit management of heart failure

    Ann Emerg Med

    (1998)
  • W.F. Peacock et al.

    Effective observation unit treatment of decompensated heart failure

    Congest Heart Fail

    (2002)
  • W.F. Peacock et al.

    Patient outcome and costs following an acute heart failure (HF) management program in an emergency department (ED) observation unit (OU)

    J Heart Lung Transplant

    (1999)
  • J.M. Kosowsky et al.

    Preliminary experience with an emergency department observation unit protocol for heart failure

    Acad Emerg Med

    (2000)
  • R.V. Aghababian

    Acutely decompensated heart failure: opportunities to improve care and outcomes in the emergency department

    Rev Cardiovasc Med

    (2002)
  • J.B. O'Connell

    The economic burden of heart failure

    Clin Cardiol

    (2000)
  • Peacock WF, Emerman CL. Preventing readmission in heart failure. Available at:...
  • A.S. Maisel et al.

    Breathing Not Properly Multinational Study Investigators: rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure

    N Engl J Med

    (2002)
  • B.J. Freda et al.

    Outcomes in HF patients with elevated cardiac markers of ischemia

    J Card Fail

    (2002)
  • W.F. Peacock

    Acute emergency department management of heart failure

    Heart Fail Rev

    (2003)
  • J. Remes et al.

    Validity of clinical diagnosis of heart failure in primary health care

    Eur Heart J

    (1991)
  • G.C. Fonarow et al.

    Risk stratification for in-hospital mortality in acutely decompensated heart failure: classification and regression tree analysis

    JAMA

    (2005)
  • U. Elkayam et al.

    Use and impact of inotropes and vasodilator therapy during heart failure hospitalization in the ESCAPE Trial

    Circulation

    (2004)
  • J.A. Hill et al.

    Pulmonary artery catheter use does not change the contribution of renal dysfunction to outcomes in patients with advanced heart failure: findings from ESCAPE

    Circulation

    (2004)
  • L. Dei Cas et al.

    Prevention and management of chronic heart failure in patients at risk

    Am J Cardiol

    (2003)
  • H.R. Black

    The burden of cardiovascular disease: following the link from hypertension to myocardial infarction and heart failure

    Am J Hypertens

    (2003)
  • A.M. Katz

    Cardiomyopathy of overload: a major determinant of prognosis in congestive heart failure

    N Engl J Med

    (1990)
  • E.J. Eichhorn et al.

    Medical therapy can improve the biological properties of the chronically failing heart: a new era in the treatment of heart failure

    Circulation

    (1996)
  • Cited by (0)

    Supervising editor: W. Brian Gibler, MD

    Funding and support: Supported by an unrestricted educational grant from Scios Inc.

    View full text