November 2022: Trial of an Intervention to Improve Acute Heart Failure Outcomes
The issue
A Canadian stepped‑wedge trial tested a hospital strategy that (1) uses the EHMRG30‑ST bedside score to label emergency‑department heart‑failure patients as low, intermediate, or high risk and (2) sends low‑risk cases home within ≤ 3 days with a rapid cardiology clinic visit. Among 5,452 patients, this approach cut 30‑day death‑or‑cardiovascular‑readmission from 14.5 % to 12.1 % (hazard ratio 0.88) and kept high‑risk patients safely in hospital.
What do I need to know?
The score is entered at the bedside and instantly classifies risk.
Low‑risk patients discharged early had < 7 % events at 30 days and < 6 events before their first clinic appointment, showing that timely outpatient follow‑up makes early discharge safe.
High‑risk patients stayed in hospital; intermediate‑risk cases could go either way, guided by judgment and follow‑up capacity.
Over 20 months the strategy still edged out usual care (hazard ratio 0.95).
Potential risk of post‑discharge complications
You are judged “low risk” by the EHMRG30‑ST tool and feel better after IV diuretics.
Recommended Actions
Confirm that discharge occurs within 3 days and that a nurse‑led heart‑failure clinic visit is booked in ≤ 7 days.
Leave with written weight‑monitoring and diuretic‑titration instructions and a phone number for sudden symptoms.
Imminent risk of post‑discharge complications
“Intermediate risk” score or multiple comorbidities but haemodynamically stable.
Recommended Actions
Ask whether a brief ward stay (≤ 3 days) plus rapid clinic follow‑up is possible; if not, request admission under medicine–cardiology shared care.
Begin guideline drugs (ACE‑/ARB/ARNI, beta‑blocker, SGLT2 inhibitor) before discharge and schedule labs within one week.
Confirmed high risk of adverse events
“High risk” score, unstable vitals, or recurrent decompensation.
Recommended Actions
Stay in hospital for optimization; ensure a geriatric‑friendly unit to prevent delirium.
Plan discharge only after weight is down, creatinine is stable, and a firm outpatient plan (clinic within five days) is in place.
What can I do?
Ask the emergency‑department team, “What is my EHMRG30‑ST risk? Am I at potential, imminent, or confirmed danger?” If low‑risk and sent home, weigh yourself daily, take diuretics as instructed, and attend the early clinic visit. Bring a list of medications and symptoms to every appointment. Caregivers should check for sudden weight gain (> 2 lb/1 kg in a day), swelling, or shortness of breath and call the clinic immediately if they appear.
