Crimson Labs

Four types of HF patients your ED staff must recognize

by Veena Lanka, MD

As I work with organizations to identify their costly drivers of poor quality, heart failure continues to top the list. Readmission penalties aside, any patient admitted with heart failure typically means $1,200 in unreimbursed costs for the hospital, according to the "Short Stay Management of Heart Failure" handbook.

This is particularly troubling because, as Collins et. al point out, 45% of all inpatient stays with heart failure are avoidable admissions. Since the ED is usually the decision threshold for these admissions, you need to accurately assess risk at triage.

There are four types of risk that can be managed in different settings:

High-risk patients

Crimson Cohort Analysis found that hospitals overestimate risk in patients presenting in the ED with signs of heart failure and end up admitting about 90% of them. This happens for three reasons:

  • Clinical symptoms of low- and high-risk patients are very similar
  • Imaging tests like EKG and chest X-Ray are often ambiguous
  • No reliable lab tests exist for heart failure

Low-risk patients

Identifying low-risk patients quickly and accurately will allow hospitals to safely release them from the ED, rather than admit them. Recent evidence shows that Brain Natriuretic Peptide (BNP) screening at triage can accurately rule out high risk: a patient with <100pg/dl BNP levels is usually not at risk of developing acute heart failure.

Hospitals can prevent unnecessary admissions by implementing universal BNP screening at triage for patients with shortness of breath. To assess your performance in this area, monitor BNP ordering rates and release rates for CHF patients in the ED.

Intermediate-risk patients

More than half of patients in the ED with suspected heart failure only partially meet admission criteria and will improve rapidly with diuretic and oxygen treatment. This makes them excellent candidates for observation rather than inpatient care, yet observation use for CHF is only 8-27% across the cohort.

Monitoring the frequency of short inpatient stays is a good way to explore whether a subset of your admitted patients are suitable candidates for observation.

Training ED staff to utilize the observation setting for intermediate-risk patients allows for a more in-depth evaluation of social and clinical risk factors, while continuing treatment and monitoring response. This is also an opportunity to initiate long-term care management plans including discharge planning, medication reconciliation, education, PCP appointments, and appropriate referrals.

Advanced disease with high mortality risk

CHF typically comes with extremely high in-hospital and post-discharge mortality rates. Crimson analysis found that less than 5% of heart failure admissions with high mortality risk have a documented palliative care encounter.

The benefits of early palliative care include better end-of-life quality for the patient and lower resource costs for hospitals. Since ED staff is positioned to quickly and uniformly initiate palliative care, they should be trained to recognize the inherent risk of mortality and proactively look for the patients’ and caregivers’ advanced life directives and resuscitation preferences.

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Recognizing these four patient types in the ED consistently can help improve patient outcomes and ensure optimal use of hospital resources. Each type must be carefully transitioned into a long-term follow-up plan in collaboration with their primary care provider and relevant specialty providers. 

What additional strategies have you employed at your organization to ensure selection of the right setting of care for heart failure management? Log in and comment below or email me at
For more information on identifying opportunities to improve heart failure outcomes at your facility, listen to our on-demand webconference. You can also reach out to your dedicated advisor for a customized performance report and additional guidance on reviewing heart failure outcomes in Crimson.