Challenges in the Management of Acutely Decompensated Congestive Heart Failure: Disposition Decisions in the Emergency Department

Tibe V ~ P n2jority ofpatients wkio presmt to the Emergency Se2adment (ED) wib deco~ykpensated heal$ faikme are acbmtted to the hospital, despite increasing pressure tc contain cost Approp~ate decisian makk g h &e E3 1s p x m o m t , O ~ V I O ~ W ! ~ very hpOdmt for bizpostic and xherapeutic manmvers bst also tr~'ae for patient ddispos~t~on. One could argu~e that patient dispssition, not maragem-ent, is the amost &u$"atk g task emergency physician faces H ~ S ~ Q I ~ ~ ~ E B J , ED physicians were forced tc mate dispositim decisums wsGl only hvo options: discha~ge hoxe aRer a relatively short ED stay or admit to the hospital. To make things more diaEmiit, these decisions were oRen made with the pressma, of Pixie md usuaily on 1i&ted &h,. Tris strategy freqdently led to i~appro-griate ad~~issno:~s and{ premamz ED discharges with resultaft ~nc~eased cost and morbidity, zespe~tively.~~' The American College of Cardiology ( A C C ) / h ~ ~ e ~ c a n Beart Association (AKA) guidelmss on the managemen1 of H~ext faikxe suggest Lbat patients w~th mild to moderate symptoms generally do not require admission Howeveq ~1k2cimfi ofier. have &fficul@jndgang the prognosis sf such patients and while lhese gGdekqes may assist k daision ;mah?g, c+hicdj~~dgemen: remai'~s Lv?ofiz,rf.' Xece2tIy, ED based abser%ration LWI~, chnical i,eclsisn tmks or &a.gyosis &hen c3iticnl ~?ethii~ays/~ot8eoas ha~ie been deveioped to aia 31 ?ie mac~genent 01se;ected pa:;ent(i~.~ X l e ~ cse , ~ hzs beer Desk d5scsrbeC " i a i ~ : ! ~ x ~ s t ?an ; ~ ~ s p h c I o ~ s ior zc%n:e cor ,3~3r j~ qc%homeg out xhe prkcnple of a s~ccessfi~B cbsen~alion strategy holds true for any clanica8 diagnosis associated with high vol~rne, high cost a ~$ylifica~t e8anacal penal* fcr mismmagamenf. Acute deco~cperasated heart fatlare cleady fdls into fiR_,s categs~j, and a namber of Bnslitxtions have applied what has vaorked with chest pain to the management sfhexi faiI~:ce.~.~