January 1, 2013Academic Emergency Medicine109 citations
View Full PaperA Risk Scoring System to Identify Emergency Department Patients With Heart Failure at High Risk for Serious Adverse Events
Structured PICO
Does the Ottawa Heart Failure Risk Scale accurately identify emergency department patients with acute decompensated heart failure at high risk for serious adverse events?
P
Population
Adult patients presenting with acute decompensated heart failure to the emergency department (n=559 visits).
I
Intervention
Ottawa Heart Failure Risk Scale (a 10-element risk scoring system)
O
Outcome
Serious adverse events (SAEs) defined as a composite of death, intubation, admission to a monitored unit, or relapse requiring admissioncomposite
The Ottawa Heart Failure Risk Scale is a newly developed, internally validated 10-element tool that accurately stratifies the risk of serious adverse events in ED patients with acute decompensated heart failure to guide admission decisions.
Abstract
OBJECTIVES: There are no validated guidelines to guide physicians with difficult disposition decisions for emergency department (ED) patients with heart failure (HF). The authors sought to develop a risk scoring system to identify HF patients at high risk for serious adverse events (SAEs). METHODS: This was a prospective cohort study at six large Canadian EDS that enrolled adult patients who presented with acute decompensated HF. Each patient was assessed for standardized clinical and laboratory variables as well as for SAEs defined as death, intubation, admission to a monitored unit, or relapse requiring admission. Adjusted odds ratios for predictors of SAEs were calculated by stepwise logistic regression. RESULTS: In 559 visits, 38.1% resulted in patient admission. Of 65 (11.6%) SAE cases, 31 (47.7%) occurred in patients not initially admitted. The multivariate model and resultant Ottawa Heart Failure Risk Scale consists of 10 elements, and the risk of SAEs varied from 2.8% to 89.0%, with good calibration between observed and expected probabilities. Internal validation showed the risk scores to be very accurate across 1,000 replications using the bootstrap method. A threshold of 1, 2, or 3 total scores for admission would be associated with sensitivities of 95.2, 80.6, or 64.5%, respectively, all better than current practice. CONCLUSIONS: Many HF patients are discharged home from the ED and then suffer SAEs or death. The authors have developed an accurate risk scoring system that could ultimately be used to stratify the risk of poor outcomes and to enable rational and safe disposition decisions.