This review will explore why such a high proportion of patients presenting to emergency departments with an acute decompensation or a new diagnosis of heart failure are hospitalized. Neither of the current guidelines from the Society of Chest Pain Centers (SCPC) and the American Heart Failure Association (AHFA) gives a blanket recommendation of admission for all patients with acute decompensated heart failure (ADHF).  The SCPC recommends that patients demonstrating renal dysfunction, low serum sodium, low systolic blood pressure (SBP), new ischemic changes on ECG, or positive cardiac troponin levels be admitted for further evaluation and treatment. The 2010 AHFA recommendations for hospitalization of ADHF patients are similar to those of the SCPC. A patient who is receiving a new diagnosis of heart failure in the ED setting will likely be acutely decompensated, but such de novo patients make up a minority (21%) of all ADHF patients.[11]  Almost all decompensated patients require intravenous diuretics, but rarely demonstrate a need for time sensitive interventions or therapies, such as intravenous ionotropes. Observation units (OU) have been addressed in the literature for over a decade, but recently have become a more prevalent topic given their potential to cut health care costs. A second option to manage ADHF without hospitalization is that of an infusion room,[17] an open access site for patients to receive IV furosemide infusions. While observation units have been predicted to reduce the financial burden of hospitalizations by 50%, it is unlikely the number of patients directly discharged from Emergency Departments will change until a better way of assessing a patient’s risk is developed.
In a retrospective cohort study, Auble et al, derived a clinical prediction rule for low-risk acute heart failure aimed at identifying those patients who are at low risk for inpatient death or serious medical complication. Until a clinical prediction rule can be validated to assist in determining low and high risk ADHF patients, it is unlikely that rates of direct discharge from EDs will change. Form distribution will be till 6 January 2013 and last date of application form submission is 7 January 2013.
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Those with BNP levels >1000 or borderline-low SPB of 100-120mmHg should have admission considered. However, patients with “previously undiagnosed heart failure with signs and symptoms of systemic or pulmonary congestion” do not automatically fall into this category. For those that do require such intensive measures, there will be no question about the appropriateness of an admission. In 2004, telemetry was considered a practice standard by the American Heart Association (AHA) for all patients presenting with acute heart failure. A pilot prospective nonrandomized observational cohort study in Miami reported no documented adverse reactions for patients receiving treatment and an avoidance of 115 ED visits. One such possibility is to create a risk assessment score which augments the physician’s knowledge for making disposition decisions; an idea analogous to the PORT scoring system.
However, alternative methods of managing these patients with observation suites and infusion room may offer a means of offsetting the high rate of hospital admissions and consequent health care expenditure. Society of Chest Pain Centers recommendations for the evaluation and management of the observation stay acute heart failure patient-parts 1–6.
Ota, Mohamad Lazkani, Paul Stander, Reducing Hospitalizations for Acute Decompensated Heart Failure: The Infusion Room Approach, Journal of the American College of Cardiology, Volume 61, Issue 24, 18 June 2013, Pages 2490-2491. To begin, current guidelines and what factors contribute to this hospitalization “epidemic” will be outlined. In this group, hospitalization should be considered on a case-by-case basis.[6] Despite this, ED physicians routinely admit all newly diagnosed heart failure patients (or all acutely decompensated patients).

This is due to the risk of ventricular and atrial arrhythmias which may be brought on by ADHF.[13] [14] A European study suggests that telemetry may not be needed, finding that medical decisions are rarely guided by the telemetry ?ndings. However the study was not designed nor adequately powered to evaluate differences in mortality of those using the infusion room and who did not.
Does in-patient ECG monitoring have an impact on medical care in chronic heart failure patients? Potential solutions to this problem, including observation units and the development of a risk stratification model, will then be considered. These units are similar to those already established for low risk chest pain in many institutions. Secondary outcomes were also significantly lower than those of high risk patients.[19] This model was validated in both retrospective and prospective cohort trials, though limited by sample size and population limitations. Open access to an outpatient intravenous diuresis program in a systolic heart failure disease management program. Bonow, Mihai Gheorghiade, Is Hospital Admission for Heart Failure Really Necessary?: The Role of the Emergency Department and Observation Unit in Preventing Hospitalization and Rehospitalization, Journal of the American College of Cardiology, Volume 61, Issue 2, 15 January 2013, Pages 121-126.
Alexander, Donna  Prognostic judgments and triage decisions for patients with acute congestive heart failure.

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