Discharging CHF

[WilcoWorld]

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I expect that many of us are being pressured, or soon will be pressured to discharge more patients with CHF exacerbations. How do you decide which CHF exacerbations can get tuned-up and discharged vs those who need to stay?

Obviously, new onset CHF and CHF exacerbations requiring BiPap and a nitro drip are staying. Obviously someone who just ran out of lasix and lisinopril yesterday and presents requesting a prescription can go home. But what about the cases in between? What do you use as your admit threshold?

 

[Arcan57]

I expect that many of us are being pressured, or soon will be pressured to discharge more patients with CHF exacerbations. How do you decide which CHF exacerbations can get tuned-up and discharged vs those who need to stay?

Obviously, new onset CHF and CHF exacerbations requiring BiPap and a nitro drip are staying. Obviously someone who just ran out of lasix and lisinopril yesterday and presents requesting a prescription can go home. But what about the cases in between? What do you use as your admit threshold?

I'll probably have to modify (if I can get appropriate outpt support) but currently I use return to baseline as my marker. If patient diureses in a couple of hours and is able to ambulate at their pre-exacerbation level they go home (absent alternative diagnosis). Of note, I send almost no one home.

 

[Interpolfanclub]

I'll probably have to modify (if I can get appropriate outpt support) but currently I use return to baseline as my marker. If patient diureses in a couple of hours and is able to ambulate at their pre-exacerbation level they go home (absent alternative diagnosis). Of note, I send almost no one home.

Ditto, I rarely send CHF home. Sent an old lady in CHF home once as a new attending since "I really want to go home doc", and she almost died before she was able to get back into the dept and get slapped on bipap. I even diuresed her in the dept and road tested her before discharge.

I just don't know how in a few hours in the ED to sort out the ones that aren't going to crash. The problem with CHF is that it can worsen in a brief period of time and kill people. I'm a really conservative physician and I don't see much upside to trucking these people out of the dept. Others would feel more comfortable with ED diuresis and road testing but not I.

 

[RustedFox]

Ditto, I rarely send CHF home. Sent an old lady in CHF home once as a new attending since "I really want to go home doc", and she almost died before she was able to get back into the dept and get slapped on bipap. I even diuresed her in the dept and road tested her before discharge.

I just don't know how in a few hours in the ED to sort out the ones that aren't going to crash. The problem with CHF is that it can worsen in a brief period of time and kill people. I'm a really conservative physician and I don't see much upside to trucking these people out of the dept. Others would feel more comfortable with ED diuresis and road testing but not I.

+3.

I admit, like, everybody. Even if you're a 'returned-to-baseline' CHF-er.... you've come to the ED with chest pain/SOB, and a TnI that I likely can't 'track'. You're now a 'chest pain' patient that needs a rule-out. Admit. Kthxbye.

No joke.

 

[dchristismi]

I admit most.

If chest pain with it, it stays.
If it's a "just wanted to catch it before it got too bad" sort of visit, it can sometimes go home, but it's very patient dependent, and very much follow-up dependent.

 

[WilcoWorld]

I agree with all of the above. I rarely discharge CHF. Thinking about my practice, I would say the single biggest determinant of d/c'ing CHF is patient preference. While not a perfect predictor, it does contain a lot of information: the patient's own sense of wellness is probably a better barometer than BNP, JVP and CXR combined, they're aware of their own resources, and, perhaps most of all, I can document in my chart that the patient was apprised of the risks and benefits and made his or her own decision to be discharged (so don't sue me).

BUT, we're probably practicing in the Golden Days. As metrics creep in, we're all likely to start getting more pushback on admitting CHF, especially if it's a readmission within 30 days. You can dig your heels in and say "CHF=admit", but that's likely to be an increasingly difficult stance to maintain. When that day comes I'd sure like to have some stratification tools or at least guidelines that I can point to - either to argue for admission, or to document in my MDM when I'm sending 'em home.

 

[southerndoc]

Not hypoxemic, tachypneic, tachycardic, or CXR showing they're fulminant wet (i.e., only treating their BNP), then I'll discharge almost all of them.

 

[anonymousEM]

Clear story of noncompliance--out of meds, ate half of the easter ham, etc and symptoms resolved in ED, usually DC from my sovereign immunity site. CP, no clear inciting factor that can be immediately modified--admit.

 

[Arcan57]

I agree with all of the above. I rarely discharge CHF. Thinking about my practice, I would say the single biggest determinant of d/c'ing CHF is patient preference. While not a perfect predictor, it does contain a lot of information: the patient's own sense of wellness is probably a better barometer than BNP, JVP and CXR combined, they're aware of their own resources, and, perhaps most of all, I can document in my chart that the patient was apprised of the risks and benefits and made his or her own decision to be discharged (so don't sue me).

BUT, we're probably practicing in the Golden Days. As metrics creep in, we're all likely to start getting more pushback on admitting CHF, especially if it's a readmission within 30 days. You can dig your heels in and say "CHF=admit", but that's likely to be an increasingly difficult stance to maintain. When that day comes I'd sure like to have some stratification tools or at least guidelines that I can point to - either to argue for admission, or to document in my MDM when I'm sending 'em home.

What's going to happen is all of these re-admit patients are going to end up being placed in obs status and getting kicked out in 23 hrs. Whether that's a clinical decision unit run by EPs or a "bedded outpatient" unit staffed by hospitalists, the trend is going to be not to make these patients full admits. I don't know if the economics work out for placing them in obs status, but CHF exacerbations typically don't require expensive testing after admission (unlike say doing CTAs, stress tests, or caths for obs chest pain patients).

 

[deleted109597]

Ah, CHF.

My favorite study on this showed that BNP number doesn't correlate with length of stay, but ordering it in the ED shortens their stay. Why?

Because they can trend it on hospital day 2, whereas if they don't get it until the second day, they have to stay another 24 hours for the second one.

Inpatient medicine. Why think when you can order tests?

 

[deleted547339]

So, dumb intern question coming:

My understanding is that dyspnea is a "Anginal Equivalent" - whatever that means. In a patient who is dyspnic secondary to obvious CHF exacerbation, I'm assuming you still get markers, because this is someone who could certainly be having an acute CHF exacerbation secondary to an acute MI. If you get markers on a CHF patient (i.e. obviously high risk for MI), are you not obligated to admit them to obs for a CP r/o since they don't fall into the low-risk 2h r/o category? Clinically, it makes sense to diurese them and d/c if they return to baseline and want to go home. Med-mal-wise, they are high risk for an MI and if they dropped dead later that day after going to the ED for dyspnea, no one would be surprised and you would definitely lose the case. I would hate to just admit every CHF-exacerbation, but I'd also hate to lose my ability to be a doctor.

Forgive my naivety. Thanks all.

 

[nlax30]

3rd year IM resident here and on receiving end of frequent CHF admits being at a primarily cardiac hospital as well hearing it daily from hospitalists, hospital admin, and case managers about readmissions.

I agree in that it's gonna be hard to send these folks home unless the starts align in regards to follow-up, pt preference, clinical improvement in ED, etc...

Question for y'all: Do any of y'all have a dedicated outpatient CHF clinic associated with your facility and if so has that changed dispo at all for any of your CHFers?

We recently started staffed with an NP during the day and while I'm not sure it would change much about an overnight CHF ED visit, it could at the least give a reliable follow up option that seems to at least plague out facility and our pt population. And then during the day it could provide a dispo where that could sent to the CHF clinic instead of possibly admitted if not an "obvious" admit.

Just curious if any had something like this that was incorporated at some level into dispo decision planning.

 

[Arcan57]

So, dumb intern question coming:

My understanding is that dyspnea is a "Anginal Equivalent" - whatever that means. In a patient who is dyspnic secondary to obvious CHF exacerbation, I'm assuming you still get markers, because this is someone who could certainly be having an acute CHF exacerbation secondary to an acute MI. If you get markers on a CHF patient (i.e. obviously high risk for MI), are you not obligated to admit them to obs for a CP r/o since they don't fall into the low-risk 2h r/o category? Clinically, it makes sense to diurese them and d/c if they return to baseline and want to go home. Med-mal-wise, they are high risk for an MI and if they dropped dead later that day after going to the ED for dyspnea, no one would be surprised and you would definitely lose the case. I would hate to just admit every CHF-exacerbation, but I'd also hate to lose my ability to be a doctor.

Forgive my naivety. Thanks all.

Excellent questions. Have a couple of thoughts on them, which are by no means definitive but may be useful.

1) All CHF is not ischemic in nature. A significant number of patients with CHF are going to have clean coronaries. There are plenty of patients who bought their CHF through years of uncontrolled BP, substance abuse, valve problems, chemo drugs, etc. At least at my current shop, non-ischemic CHF probably accounts for 60-70% of total CHF patients.

2) I think about the mortality associated with CHF as coming from 3 sources - respiratory failure (which we are usually good at recognizing in the impending state), arrhythmias (hence all the AICDs, hospitalization of someone who didn't present with an arrhythmia probably isn't useful unless there's a modifiable risk factor that puts them at high risk), and secondary disease states masquerading as CHF exacerbations. MIs, PEs (there's some bat crap study claiming a 25% incidence of PEs in admitted CHF patients), pneumonia all can masquerade as CHF. I think the two hour rule-out is appropriate for CHF patients if they are non-ischemic in nature and that does give you some time to see how they're diuresing.

With the above mentality, I probably send home a CHF patient presenting with symptoms of an exacerbation every couple of weeks to every month.

 

[Bostonredsox]

3rd year IM resident here and on receiving end of frequent CHF admits being at a primarily cardiac hospital as well hearing it daily from hospitalists, hospital admin, and case managers about readmissions.

I agree in that it's gonna be hard to send these folks home unless the starts align in regards to follow-up, pt preference, clinical improvement in ED, etc...
Question for y'all: Do any of y'all have a dedicated outpatient CHF clinic associated with your facility and if so has that changed dispo at all for any of your CHFers?

We recently started staffed with an NP during the day and while I'm not sure it would change much about an overnight CHF ED visit, it could at the least give a reliable follow up option that seems to at least plague out facility and our pt population. And then during the day it could provide a dispo where that could sent to the CHF clinic instead of possibly admitted if not an "obvious" admit.

Just curious if any had something like this that was incorporated at some level into dispo decision planning.

agreed. i think nearly every true CHF exac you guys see is worth having us come and see the pt. 99/100 were going to admit them. CHF exac, generally do to flash pulmonary edema from uncontrolled HTN, is the #1 admission diagnosis in the US (excluding chest pain observations and other non inpatient dx).

very very uncommon for a CHF that is truly exacerbated to get sent home. And I completely agree with the plan for admission.

I suppose if it is a well followed pt, with not too terrible LV function, who is not hypoxic, who responds well to a single shot of loop diuresis, and can definitely be seen the next morning by their PCP....thats ok. Still risky to me though. i think at minimum they warrant an overnight stay with monitored IV diuresis, a recheck of the electrolytes and ekg and close observation of their pulmonary status.

 

[gman33]

Anyone want to comment on the general ED management of these folks?

EM tends to go for nitro, BiPaP, maybe an ACE.
IM seems to go more for Lasix, etc.

I lean more towards the former, but when admitting get questioned about not doing the later.

 

[Arcan57]

Anyone want to comment on the general ED management of these folks?

EM tends to go for nitro, BiPaP, maybe an ACE.
IM seems to go more for Lasix, etc.

I lean more towards the former, but when admitting get questioned about not doing the later.

The literature suggests nitro (and lots of it) as being the treatment of choice for decompensated CHF. Hopefully by the time they get to the floor they've stabilized and the internist can focus on optimizing volume status. From what I remember, aggressive diuresis increases mortality compared to high dose nitro gtt.

 

[Hair Police]

I generally admit the patient with slowly decompensating CHF (inc dyspnea on exertion and pedal edema, dec exercise tolerance, etc. for diuresis and monitoring, as bostonredsox says. Those who have true flash pulmonary edema, I treat w NTG, BIPAP, and ACE. Lasix generally comes much later, and not given until the patient has proven that their renal blood flow has improved (they start to diurese), and their respiratory distress (the emergent issue) has improved. For more details, read this.

 

[xaelia]

Not all decompensated heart failure is hypervolemic. Furosemide is appropriate in selected patients, but after the acute symptomatic treatment.

 

[WilcoWorld]

There is plenty to be discussed about the management of decompensated CHF with pulmonary edema and respiratory distress, enough to start a new thread (hint-hint).

My question was more about people with a CHF history who present with dyspnea, and you find them to be at their baseline (maybe that baseline is a BNP = 760 and O2 = 94% on 2L/min and an abnormal, but unalarming ECG). What do you do with those people once you've determined that there's nothing wrong with them but their ol' CHF?

 

[Hair Police]

There is plenty to be discussed about the management of decompensated CHF with pulmonary edema and respiratory distress, enough to start a new thread (hint-hint).

My question was more about people with a CHF history who present with dyspnea, and you find them to be at their baseline (maybe that baseline is a BNP = 760 and O2 = 94% on 2L/min and an abnormal, but unalarming ECG). What do you do with those people once you've determined that there's nothing wrong with them but their ol' CHF?

if they're having subjective dyspnea, you can usually pull out of them a quantitative measure of exercise intolerance (on my best day, I can walk around the block without resting, today I can barely walk across the room [2/2 to a daily regimen of sausage weenies and medication non-compliance!]) or an exam finding (crackles in lung bases, changes on CXR, return/worsening of edema). If you can't find anything else on H and P, I entertain other diagnoses (PE?).

 

[Groove]

There is plenty to be discussed about the management of decompensated CHF with pulmonary edema and respiratory distress, enough to start a new thread (hint-hint).

My question was more about people with a CHF history who present with dyspnea, and you find them to be at their baseline (maybe that baseline is a BNP = 760 and O2 = 94% on 2L/min and an abnormal, but unalarming ECG). What do you do with those people once you've determined that there's nothing wrong with them but their ol' CHF?

I discharge the vanilla CHF exacerbation that does not have a worrisome clinical picture and that I can get back to baseline pretty quickly. Many pt's just skip their lasix and eat a garbage truck full of salted popcorn before showing up in the ED. I discharge about 40% on average and admit the rest. Obviously if their BNP is 5x greater and they have a progressive decompensated picture or any other weirdness, they get admitted but I have no problem discharging the simple ones. We have a lot of CHF'ers down here and most of them are non compliant with their meds.

 

[Rendar5]

I discharge the vanilla CHF exacerbation that does not have a worrisome clinical picture and that I can get back to baseline pretty quickly. Many pt's just skip their lasix and eat a garbage truck full of salted popcorn before showing up in the ED. I discharge about 40% on average and admit the rest. Obviously if their BNP is 5x greater and they have a progressive decompensated picture or any other weirdness, they get admitted but I have no problem discharging the simple ones. We have a lot of CHF'ers down here and most of them are non compliant with their meds.

Honestly I can't remember tthe last vanilla CHF exacerbation I had. My CHF patients usually only come in if there's a major issue, like their lasix isn't working (that one actually had started disobeying doctor's orders by taking EXTRA lasix when they started to have a weight increase and it still failed to have any effect due to bowel wall edema reducing absorption)

 

[Groove]

Honestly I can't remember tthe last vanilla CHF exacerbation I had. My CHF patients usually only come in if there's a major issue, like their lasix isn't working (that one actually had started disobeying doctor's orders by taking EXTRA lasix when they started to have a weight increase and it still failed to have any effect due to bowel wall edema reducing absorption)

Really? What's your patient population like? I feel like I see a CHF'er every shift. My last one had ran out of lasix for the past 4 days and simply didn't get around to get it refilled. Diuresed, d/c'd. We have a large AA population. Many of which are IDC that present with a very typical progressive exacerbation due to inadequate diuresis. I guess that's what I mean when I say "vanilla".

 

[Rendar5]

Really? What's your patient population like? I feel like I see a CHF'er every shift. My last one had ran out of lasix for the past 4 days and simply didn't get around to get it refilled. Diuresed, d/c'd. We have a large AA population. Many of which are IDC that present with a very typical progressive exacerbation due to inadequate diuresis. I guess that's what I mean when I say "vanilla".

weird mix honestly, I get my share of chronic painers, IVDA's, noncompliant diabetics, drunks. But I get less than my share of stupid/lazy CHF patients and more than my share of intractable pukers and chronic GI'ers

 

[Rendar5]

Really? What's your patient population like? I feel like I see a CHF'er every shift. My last one had ran out of lasix for the past 4 days and simply didn't get around to get it refilled. Diuresed, d/c'd. We have a large AA population. Many of which are IDC that present with a very typical progressive exacerbation due to inadequate diuresis. I guess that's what I mean when I say "vanilla".

weird mix honestly, I get my share of chronic painers, IVDA's, noncompliant diabetics, drunks, etc.. But I get less than my share of stupid/lazy CHF patients and more than my share of intractable pukers and chronic GI'ers

 

[pratik7]

I send a chf-er home once a month or so. Like many other, you have to have follow up. Not tachypenic, hypoxic and a relatively normal cxr. I usually dont use the BNP as a guide to admit( unless i want to admit and use it to my advantage). I do usually call their cardiologist and let them know. Never carry the casket alone

 

[Dr. Ditka]

Have any of you guys used any scoring systems to support reasons for discharge? For example, the Emergency Heart Failure Mortality Risk Grade is a tool that I've seen that looks at 7 day mortality. Like all hospitals, mine is looking at decreasing readmissions and I would like a tool to help support my decision making.
Have any of you utilized an outpatient process with follow up that has worked well?

 

[Siggy]

Ah, CHF.

My favorite study on this showed that BNP number doesn't correlate with length of stay, but ordering it in the ED shortens their stay. Why?

Because they can trend it on hospital day 2, whereas if they don't get it until the second day, they have to stay another 24 hours for the second one.

Inpatient medicine. Why think when you can order tests?

Trending BNPs... slightly more worthless than trending lipase.

...and don't get me started on the "ZOMG, THE BNP IS 2000, CHF EXACERBATION!!!11ONE." Pants on head stupid.

 

[Siggy]

Clinically, it makes sense to diurese them and d/c if they return to baseline and want to go home. Med-mal-wise, they are high risk for an MI and if they dropped dead later that day after going to the ED for dyspnea, no one would be surprised and you would definitely lose the case. I would hate to just admit every CHF-exacerbation, but I'd also hate to lose my ability to be a doctor.

Forgive my naivety. Thanks all.

It's going to largely depend on the story. Slowly getting worse? Out of meds? Drinks like someone who just crawled out of Death Valley?

or

"I was at home minding my own business when all of a sudden. BAM CHF EXACERBATION!"?

 

[deleted547339]

It's going to largely depend on the story. Slowly getting worse? Out of meds? Drinks like someone who just crawled out of Death Valley?

or

"I was at home minding my own business when all of a sudden. BAM CHF EXACERBATION!"?

You acts as if my patients know how to tie their own shoes...

 

[Siggy]

You acts as if my patients know how to tie their own shoes...

My patients are smart enough to wear Velcro shoes so they don't have to tie their own shoes.

 

[Xerxes1729]

CHF exacerbations start from a presumption of admission and I need to see some pretty convincing reasons otherwise to send them home.

 

[Instatewaiter]

I think a lot of heart failure can be handled as an outpatient but a lot of PCPs don't want to have to deal with outpatient diuresis. IMO there are only a handful of things that need to be admitted.
- hypoxia- no brainer
- Low output
- Significant end organ damage from congestion (renal dysfunction, elevated LFTs)
- Active ischemia (not just chest pain)
- Cannot do this at home (lack of resources)
- Oral diuretics aren't working and already had home diuretics doubled as an outpatient
- Multiple ICD discharges + volume overload
- ****tons of fluid needs to be diuresed (40+ lbs)

A lot of these run-of-the-mill heart failure exacerbations can be given IV diuretics x 1. If they respond well, send home on double dose of home diuretic with close follow up. If during follow up in a few days they aren't diuresing they should be directly admitted. A lot of heart failure cardiologists are setting up these IV diureic outpatient clinics to prevent these things from going to the ED in general and reduce the pressure on the ED to admit.

 

[Siggy]

they should be directly admitted.

Directly admitted? People do that for things besides scheduled surgeries? /sarcasm

 

[Instatewaiter]

Directly admitted? People do that for things besides scheduled surgeries? /sarcasm

Haha. I've heard it happens.

 

[WilcoWorld]

Directly admitted? People do that for things besides scheduled surgeries? /sarcasm

Yeah, they get admitted directly to the ED.