Systemizing the Evaluation of Acute Heart Failure in the Emergency Department

Introduction of the Hospital Readmission Reduction Program, imposing financial penalties for early readmissions after hospital discharge, has created a strong incentive for hospitals to reduce heart failure (HF) admissions, often by risk-stratifying patients before discharge for more intensive follow-up or disease management programs.A less explored option for reducing readmissions is risk-stratifying patients presenting to the emergency department (ED) to identify those who can be managed safely at home.Exploring this opportunity is important, given that the ED plays a pivotal role in HF care, with nearly 80% of patients evaluated being admitted.1 The current decision to admit these patients is based on clinical judgment, with large regional and hospital-level variability in readmission rates. 2 At our institution, the rate of HF discharge from the ED across the 46 ED physicians in the 2016 calendar year was 20% and varied from 0 to 34%.To better identify patients warranting admission, we developed and implemented a standardized care path, Code Heart Failure (CodeHF) for evaluating patients with acute HF presenting to the ED.This report describes the creation and implementation of the CodeHF pathway, along with early insights into its promise and pitfalls. GOALS AND VISION OF THE PROGRAMThe primary goal of this initiative was to improve care for patients with HF exacerbations presenting to the ED through early identification, evidence-based risk stratification, education, and timely follow-up. LOCAL CHALLENGES IN IMPLEMENTATIONDespite leadership by an Emergency physician (Dr Scholes), it was well recognized that there would be resistance to practice change due to poor coordination between medical specialties, lack of infrastructure for an evidence-based, standardized method of triage, minimal education for acute HF in the ED, and the perception that HF management had not been identified as an important opportunity for quality improvement.To address this, a multidisciplinary team was formed that involved all relevant stakeholders (ED physicians, cardiologists, HF disease management nurses, administration, and researchers).Serial biweekly meetings were held to design the intervention and oversee its implementation.

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