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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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.
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