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Disposition of emergency department patients diagnosed with acute heart failure: an international emergency medicine perspective

Miró, Òscar; Levy, Philip D.; Möckel, Martin; Pang, Peter S.; Lambrinou, Ekaterini; Bueno, Héctor; Hollander, Judd E.; Harjola, Veli-Pekka; Diercks, Deborah B.; Gray, Alasdair J.; DiSomma, Salvatore; Papa, Ann M.; Collins, Sean P.

European Journal of Emergency Medicine: February 2017 - Volume 24 - Issue 1 - p 2–12
doi: 10.1097/MEJ.0000000000000411
Review Articles

Many patients with acute heart failure are initially managed in emergency departments (EDs) worldwide. Although some require hospitalization for further management, it is likely that a sizeable proportion could be safely discharged either directly from the ED or after a more extended period of management in an observation-type unit. Identification of low-risk patients who are safe for such an approach to management continues to be a global unmet need. This is driven in part by a lack of clarity on postdischarge outcomes for lower risk patients and a nonexistent consensus on what may be acceptable event rates. The current paper reviews previous studies carried out on patients directly discharged from the ED, suggests a general disposition algorithm and focuses on discharge metrics, which are based on both evidence and expert opinion. In addition, we propose that the following variables be considered for future determination of acceptable event rates: (a) baseline characteristics and risk status of the patient; (b) access to follow-up; (c) ED capability to provide an extended period of observation before discharge; (d) the temporal relationship between the event and ED discharge decision; and (e) the type of event experienced.

aEmergency Department, Hospital Clínic, Barcelona, Catalonia, ‘Emergencies: Processes and Pathologies’ Research Group, IDIBAPS, Barcelona

bCatalonia, and ICD-SEMES Research Group, 6Instituto de investigación i+12 Research Institute and Cardiology Department, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Spain

cDepartment of Cardiology, Division of Emergency Medicine, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum und Charité Mitte, Berlin, Germany

dDepartment of Nursing, School of Health Sciences, Cyprus University of Technology, Limassol, Cyprus

eDepartment of Medical-Surgery Sciences and Translational Medicine Emergency Department Sant’Andrea Hospital, University of Rome La Sapienza, Rome, Italy

fDepartment of Emergency Care, Division of Emergency Medicine, Helsinki University and Helsinki University Hospital, Helsinki, Finland

gEmergency Medicine Research Group, Department of Emergency Medicine, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK

hDepartment of Emergency Medicine and National Academic Center for Telehealth, Philadelphia, Sidney Kimmel Medical College of Thomas Jefferson University

iEinstein Medical Center Montgomery; Vice President & Chief Nursing Officer, East Norriton, Pennsylvania

jDepartment of Emergency Medicine and Cardiovascular Research Institute, Wayne State University, Detroit, Michigan

kDepartment of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana

lDepartment of Emergency Medicine, University of Texas Southwestern, Dallas, Texas

mDepartment of Emergency Medicine, Vanderbilt University, and The Veterans Health Administration, Nashville, Tennessee, USA

Correspondence to Òscar Miró, PhD, MD, Emergency Department, Hospital Clínic, Villarroel 170, 08036 Barcelona, Catalonia, Spain Tel: +34 932 279 833; fax: +34 932 275 693; e-mail:

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Received February 25, 2015

Accepted May 11, 2016

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