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Impact of the MEESSI-AHF tool to guide disposition decision-making in patients with acute heart failure in the emergency department: a before-and-after study
  1. Òscar Mirò1,
  2. Pere Llorens2,
  3. Xavier Rosselló3,
  4. Víctor Gil1,
  5. Carolina Sánchez4,
  6. Javier Jacob5,
  7. Pablo Herrero-Puente6,
  8. María Pilar López-Diez7,
  9. Lluis Llauger8,
  10. Rodolfo Romero9,
  11. Marta Fuentes10,
  12. Josep Tost11,
  13. Carlos Bibiano12,
  14. Aitor Alquézar-Arbé13,
  15. Enrique Martín-Mojarro14,
  16. Héctor Bueno15,
  17. Frank Peacock16,
  18. Francisco Javier Martin-Sanchez17,
  19. Stuart Pocock18
  1. 1 Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Spain
  2. 2 Emergency Department, Alicante General University Hospital, Alicante, Spain
  3. 3 Cardiology Department, Son Espases University Hospital, Palma, Spain
  4. 4 Emergency Department, Clinic Barcelona Hospital University, Barcelona, Spain
  5. 5 Emergency Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, Spain
  6. 6 Emergency Department, Hospital Universitario Central de Asturias, Oviedo, Spain
  7. 7 Emergency Department, Hospital Universitario de Burgos, Burgos, Spain
  8. 8 Emergency Department, Hospital Universitari de Vic, Vic, Spain
  9. 9 Emergency Department, Getafe University Hospital, Getafe, Spain
  10. 10 Emergency Department, Hospital Universitario de Salamanca, Salamanca, Spain
  11. 11 Urgencias, Consorci Sanitari de Terrassa, Terrassa, Spain
  12. 12 Emergency Department, Hospital Infanta Leonor, Madrid, Spain
  13. 13 Emergency Department, Universitat Autònoma de Barcelona, Barcelona, Spain
  14. 14 Emergency Service, Hospital Sant Pau i Santa Tecla, Tarragona, Spain
  15. 15 Cardiology Service, Gregorio Maranon General University Hospital, Madrid, Spain
  16. 16 Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
  17. 17 Emergency, San Carlos Clinic Hospital, Madrid, Spain
  18. 18 Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
  1. Correspondence to Dr Òscar Mirò, Emergency Department, Hospital Clinic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, 08036, Spain; omiro{at}


Objectives To determine the impact of risk stratification using the MEESSI-AHF (Multiple Estimation of risk based on the Emergency department Spanish Score In patients with acute heart failure) scale to guide disposition decision-making on the outcomes of ED patients with acute heart failure (AHF), and assess the adherence of emergency physicians to risk stratification recommendations.

Methods This was a prospective quasi-experimental study (before/after design) conducted in eight Spanish EDs which consecutively enrolled adult patients with AHF. In the pre-implementation stage, the admit/discharge decision was performed entirely based on emergency physician judgement. During the post-implementation phase, emergency physicians were advised to ‘discharge’ patients classified by the MEESSI-AHF scale as low risk and ‘admit’ patients classified as increased risk. Nonetheless, the final decision was left to treating emergency physicians. The primary outcome was 30-day all-cause mortality. Secondary outcomes were days alive and out of hospital, in-hospital mortality and 30-day post-discharge combined adverse event (ED revisit, hospitalisation or death).

Results The pre-implementation and post-implementation cohorts included 1589 and 1575 patients, respectively (median age 85 years, 56% females) with similar characteristics, and 30-day all-cause mortality was 9.4% and 9.7%, respectively (post-implementation HR=1.03, 95% CI=0.82 to 1.29). There were no differences in secondary outcomes or in the percentage of patients entirely managed in the ED without hospitalisation (direct discharge from the ED, 23.5% vs 24.4%, OR=1.05, 95% CI=0.89 to 1.24). Adjusted models did not change these results. Emergency physicians followed the MEESSI-AHF-based recommendation on patient disposition in 70.9% of cases (recommendation over-ruling: 29.1%). Physicians were more likely to over-rule the recommendation when ‘discharge’ was recommended (56.4%; main reason: need for hospitalisation for a second diagnosis) than when ‘admit’ was recommended (12.8%; main reason: no appreciation of severity of AHF decompensation by emergency physician), with an OR for over-ruling the ‘discharge’ compared with the ‘admit’ recommendation of 8.78 (95% CI=6.84 to 11.3).

Conclusions Implementing the MEESSI-AHF risk stratification tool in the ED to guide disposition decision-making did not improve patient outcomes.

  • emergency department
  • heart failure
  • risk management

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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  • Handling editor Edward Carlton

  • Contributors OM conceived and designed the study. PL, XR, VG, CS, JJ, PH-P, MPL-D, LL, RR, MF, JT, CB, AA-A, EM-M, HB, FP, FJM-S and SP conducted the data analysis. All authors contributed to the implementation, data acquisition, manuscript preparation and subsequent revisions. OM is the guarantor.

  • Funding This study has been funded by the Instituto de Salud Carlos III (ISCIII) through the project PI18/00393 and co-funded by the European Union. Additional funding has also been received from grants PI15/01019, PI15/00773, PI18/00456 of the ISCIII (co-funded by the European Union) and from Fundació La Marató de TV3 (2015/2510). The 'Emergencies: Processes and Pathologies' research group of the IDIBAPS receives financial support from the Catalonian Government for Consolidated Groups of Investigation (GRC 2009/1385 and 2014/0313). XR has received support from the SEC-CNIC CARDIOJOVEN fellowship programme.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.