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

Nearly all emergency department (ED) patients with congestive heart failure (CHF) are admitted to the hospital. Some of these patients might be best served by an explicit protocol for observation and treatment in the ED. OBJECTIVE: To describe the natural history of patients with CHF who are managed in an ED-based observation unit. METHODS: Patients presenting to the ED between 7/99 and 12/99 with symptoms of CHF were screened for eligibility. Patients with hemodynamic instability, respiratory failure, acute myocardial infarction, newonset heart failure, or severe complicating medical disease were excluded. Patients were managed in the observation unit for up to 12 hours before being admitted to the hospital. Clinical parameters including heart rate (HR), respiratory rate (RR), net diuresis, and global assessment of clinical severity (GACS) score, were charted. Patients were followed for 30 days to determine length of hospital stay (LOS), rates of morbidity, mortality, and readmission. RESULTS: Twenty-four patients (15 males, 9 females; median age = 58) were enrolled in the protocol. By 4 hr a reduction in HR and RR was seen in the majority of patients (19/24 and 13/24, respectively). By 6 hr the majority (13/24) had improvement in GACS, and by 12 hours nearly all (21/24) did. By 12 hr, most patients (13/24) had a net diuresis of >1500 mL. Upon completion of the protocol, inpatient length of stay was generally brief (median LOS = 1 day; range 1-8 days). At 30 days there were no deaths or adverse events observed. Four patients were readmitted to the hospital; 2 of these admissions were related to CHF. CONCLUSIONS: In this low-risk group of patients with CHF, most showed clinical improvement within 6 to 12 hours after ED arrival. Further study is needed to determine whether an observation-unit protocol can safely and effectively reduce LOS for these patients.