Chest radiograph suggestive of pneumonia

a These criteria are meant to discourage entry by patients not likely to benefit from an aggressive diuresis and vasodilation management protocol.

with a BUN less than 43, adding systolic BP provides additional prognostic data. In this group, the addition of a systolic BP < 115 mm Hg was associated with a mortality rate of 5.49% compared with those with a higher BP whose mortality was 2.89%.

OU admission candidates should have a BUN < 43 and careful consideration if admitted with a systolic BP < 115 mm Hg.

Other studies have specifically examined OU outcome predictors for HF. In 499 patients, Diercks and colleagues [61] reported that a negative troponin and an initial systolic BP > 160 mm Hg identified a cohort who were successfully discharged within 24 hours of admission and had no death or re-hospitalization within the subsequent 30 days. Burkhardt and colleagues [62] reported in 385 OU patients that successful discharge from the OU within 24 hours of an admission for decompensated HF was predicted by an admission BUN < 30 mg/dL. These parameters may also be considered to assist in the selection of the appropriate OU candidate.

Once admitted to the OU, many different aspects of medical management are needed to assure optimal outcomes and discharge rates. Attention to the many details required for HF management [63,64] can be daunting for a physician already running a busy ED. This not only includes medication intervention and titration, but the diagnostic evaluation, patient education, and the discharge planning required by regulatory agencies. HF protocols drive treatment algorithms and provide superior outcomes, as compared with standard therapy, and ensure that required interventions are accomplished [4,58].

ED OU protocol-driven management has been shown to result in a significant improvement in outcomes, as compared with independent physician-driven care. In a before and after study of 154 decompensated OU HF patients, a prespe-cified management protocol resulted in significant outcome improvements [4]. Use of the protocol resulted in 90-day ED HF revisit rates declining by 56% (0.90 to 0.51, P — .0000) compared with pre-protocol management. Similarly, 90-day HF reho-spitalizations decreased by 64% (0.77 to 0.50, P — .007). Lastly, 90-day mortality and OU HF readmissions decreased from 4% to 1% (P — .096), and 18% to 11% (P — .099), respectively. From a cost perspective, during the same time period, annualized hospital costs declined by nearly $100,000, predominately the result of 30-day readmission avoidance [65].

The only validated OU HF protocol published to date includes an aggressive diuretic algorithm, initiated in the ED, and continued throughout the OU stay [4,58]. In this protocol, additional diuretic use was driven by the patient's urine output. If the urine output was inadequate, inpatient admission for invasive monitoring was suggested. Additionally, ACE inhibitor algorithms encouraged physician initiation and up-titration toward target levels, provided there were no renal function contraindications, systolic blood pressure was adequate, and there was no history of ACE inhibitor intolerance. Unless there are significant contraindications (eg, anaphylaxis), all HF patients should be discharged on an ACE inhibitor [1].

The OU provides an opportunity for more extensive evaluation than can be performed in most EDs. EF measurement may be determined in those without an established diagnosis of systolic HF. This should be repeated if PSF HF was previously diagnosed, and it has been more than 1 year since the last assessment of ventricular function. The OU environment also offers the option of elective multidisciplinary consultations, not available in a busy ED, for those who may have transportation difficulties in getting to an outpatient appointment. While in the OU, the option of HF cardiology specialist consultation may help to evaluate discharge medication dosages, and screen candidates for heart transplantation listing. Other ancillary care staff may consult also. This includes dietetics and home health care. Social workers can ensure that all patients have the ability to obtain their medicines and can arrange a home environment assessment to assess the potential of other psychosocial, cultural, or economic factors that could prevent therapeutic compliance. A home health care consultation serves to ensure post-discharge follow-up care and can help arrange visiting nurse services for home bound or nonambulatory patients.

Because noncompliance causes up to 50% of HF rehospitalizations [63,64,66], patient education is a critical facet in the treatment program. Bedside teaching videotapes on HF may provide detailed education during a teachable moment for the patient. Finally, patients should be provided with HF literature, medication information, and lifestyle modification suggestions at discharge.

OU HF management not only impacts the OU, it results in changes in the inpatient HF population as well. By treating selected patients in the

OU, rather than the inpatient unit, patients are diverted to less intensive levels of care. After implementation of an OU HF management protocol, inpatient acuity as indexed by the mean number of billable procedures per HF patient, increased by 11% [65]. This provides improved resource matching between patients requiring intensive monitoring environments and those who could benefit from less costly OU care.

Therapeutic agents

HF management is a complicated task. It requires the successful interaction of many different medications, individual titration regimens, patient factors (eg, education and compliance issues), and multidisciplinary services. Clearly defined patient care management programs addressing these issues have demonstrated clinical and financial success in both the OU and outpatient environment [4,58,63-67]. A validated management protocol is provided in Box 7.

Very large trials provide evidence-based data for managing stable, systolic HF. The principal drugs are beta-blockers, ACE inhibitors, angio-tensin-receptor blockers (ARBs), hydralazine/ni-trates, diuretics, digoxin, and spironolactone. In general, the strategy focuses on maintaining the lowest possible BP that allows mentation, ambu-lation, and urination [1]. All HF patients without contraindications should be on an ACE inhibitor and beta-blocker, even in the setting of stable disease with minimal symptoms. In most diseases, therapy is driven by continuing symptoms; this is not the situation in HF because of the unique neurohormonal antagonism requirements for the treatment of HF.

The emphasis on neurohormonal antagonism in HF represents a major management shift. The relief of congestion by the use of diuretics has been the main thrust of ED therapy. Although diuretics are important for acute symptomatic congestion relief, they do not improve mortality. Very large studies evaluating the role of ACE inhibitors, beta-blockers, and other agents show neurohormonal antagonism is required for the greatest mortality improvement.


Initial OU HF therapeutic goals are directed at the relief of congestion by the use of IV diuretics. Recommended dosing strategies are to use up to twice the daily dose of furosemide (or its equivalent) administered as an IV bolus, to a maximum

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