January 9th, 2013

Observation Units for Heart Failure Could Reduce Unnecessary Hospitalizations

Two new papers published in the Journal of the American College of Cardiology propose that most heart failure (HF) patients who present to the emergency department (ED) don’t need to be hospitalized and can be safely managed in an observation unit. Currently, the vast majority of HF patients  who show up in the ED are hospitalized.

In the first paper, Sean Collins and colleagues note that although HF patients have high event rates after hospital discharge, “it is not clear that hospitalization per se is the answer to decreasing these post-discharge event rates.” Most HF patients admitted to the hospital suffer only from congestion and don’t require complex therapies. A basic physical exam and diagnostic tests can identify most high-risk patients, who constitute only about 20% of all HF patients in the ED. Low-risk patients can be discharged after a short observation period. Intermediate-risk patients can receive continued treatment and observation but avoid a conventional, expensive hospitalization.

The authors propose a national program to disseminate successful protocols and local programs to encourage collaboration among emergency physicians, cardiologists, hospitalists, and primary care physicians. Observational units, they argue, should now be tested in a large randomized clinical trial.

In the second paper, Ashkay Desai and Lynne Stevenson agree that “the need for alternate routes to steer around heart failure hospitalization is indisputable, as is the need to embark on them without delay.” But, they contend, “there are daunting challenges to the immediate implementation of a randomized clinical trial.” They point out that there has been no validation on the patient selection or test parameters that would be required for such a trial. “The emergence of a single, uniformly effective strategy is not likely,” they write.

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