Heart failure risk scale validated for clinical practice

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0818-News-Students riskA study has found the Ottawa Heart Failure Risk Scale (OHFRS) tool to be highly sensitive for serious adverse event in acute heart failure patients and can now be used in clinical practice to estimate short-term risk when deciding discharge in emergency department without hospital admission.

Further, when available, the prediction tool works even better when adding a simple blood test (NT-ProBNP). The OHFRS may, therefore, be useful to allow the safe discharge of patients with heart failure in the emergency department without hospital admission.

That is the main finding of a study led by Dr Ian G Stiell.

Stiell’s new study suggests that with adequate physician training, OHFRS will be a useful tool for making rational disposition plans in the ED and should help improve and standardise admission practices, diminishing both unnecessary admissions for low-risk patients and unsafe discharge decisions for high-risk patients and ultimately leading to improved safety for patients and more efficient use of precious hospital resources.

“Our goal is to improve care for our ED patients with heart failure by identifying those at higher risk for poor outcomes through use of the OHFRS. Those with higher scores should be admitted while the many patients with lower scores could be discharged home. When available quantitative NT-ProBNP values improve accuracy of the scale.” said Stiell, professor, department of emergency medicine, University of Ottawa; distinguished professor and clinical research chair, University of Ottawa; senior scientist, Ottawa Hospital Research Institute; and emergency physician, The Ottawa Hospital.

Abstract
Objectives: We previously developed the Ottawa Heart Failure Risk Scale (OHFRS) to assist with disposition decisions for acute heart failure patients in the emergency department (ED). We sought to prospectively evaluate the accuracy, acceptability, and potential impact of OHFRS.
Methods: This prospective observational cohort study was conducted at six tertiary hospital EDs. Patients with acute heart failure were evaluated by ED physicians for the 10 OHFRS criteria and then followed for 30 days. Quantitative NT-proBNP was measured where feasible. Serious adverse event (SAE) was defined as: death within 30 days, admission to monitored unit, intubation, non-invasive ventilation, myocardial infarction, or relapse resulting in hospital admission within 14 days.
Results: We enrolled 1,100 patients with mean age 77.7 years. SSOs occurred in 170 (15.5%) cases (19.4% if admitted and 10.2% if discharged). Compared to actual practice, using an admission threshold of OHFRS score >1 would have increased sensitivity (71.8% vs. 91.8%) but increased admissions (57.2% vs. 77.6%). For 684 cases with NT-proBNP values, using a threshold >1 would have significantly increased sensitivity (69.8% vs. 95.8%) while increasing admissions (60.8% vs. 88.0%). In only 11.9% of cases did physicians indicate discomfort with use of OHFRS.
Conclusion: Prospective clinical validation found the OHFRS tool to be highly sensitive for SAEs in acute heart failure patients, albeit with an increase in admission rates. When available, NT-proBNP values further improve sensitivity. With adequate physician training, OHFRS should help improve and standardize admission practices, diminishing both unnecessary admissions for low-risk patients and unsafe discharge decisions for high-risk patients.

Authors
Ian G Stiell, Jeffrey J Perry, Catherine M Clement, Robert J Brison, Brian H Rowe, Shawn D Aaron, Andrew McRae, Bjug Borgundvaag, Lisa A Calder, Alan J Forster, George A Wells

Society of Academic Emergency Medicine material
Academic Emergency Medicine abstract


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