Short Stay Unit vs Hospitalization in Acute Heart Failure
Short Stay Unit vs Hospitalization in Acute Heart Failure
The majority of the over one million annual AHF hospitalizations originate from the emergency
 department. Admitting and re-admitting lower risk AHF patients who don't need prolonged
 hospitalization may increase their risk for poor outcomes and decrease their quality of life:
 Safe alternatives to hospitalization from the ED are needed. We propose a strategy-of-care,
 short stay unit management of AHF (i.e. less than 24 hours), will lead to improved outcomes
 for lower risk AHF patients.
Nearly 85% of acute heart failure (AHF) patients who present to the emergency department (ED)
 with acute heart failure (AHF) are hospitalized. Once hospitalized, within 30 days
 post-discharge, 27% of patients are re-hospitalized or die. Attempts to improve outcomes with
 novel therapies have all failed. The evidence for existing AHF therapies are poor: No
 currently used AHF treatment is known to improve outcomes. ED treatment is largely the same
 today as 40 years ago. Hospitalizing patients who don't need it may contribute to adverse
 outcomes. Hospitalization is not benign; patients enter a vulnerable phase post-discharge, at
 increased risk for morbidity and mortality. Patients would prefer to be home, not
 hospitalized. Furthermore, hospitalization and re-hospitalization for AHF predominantly
 affects patients of lower socioeconomic status (SES). Avoiding hospitalization in patients
 who don't need it may improve outcomes and quality of life, while reducing costs.

 Short stay unit (SSU: less than 24 hours) management of AHF is effective for lower risk
 patients. However, it's only been studied in small studies or retrospective analyses. In
 addition, some have considered the SSU 'cheating' for hospitals trying to avoid 30 day
 readmission penalties, since SSU or observation didn't count as an admission. However, this
 quality measure is now changing. A robust clinical effectiveness trial would demonstrate the
 effectiveness of this patient-centered strategy.

 Using a multi-center, randomized controlled design, this clinical effectiveness trial will
 test whether Short Stay Unit AHF management for < 24 hours increases
 days-alive-and-out-of-hospital, Quality of Life assessment (QoL), caregiver burden, and costs
 compared to inpatient management.
Inclusion:

 1. ED physician clinical diagnosis of AHF;

 2. Planned admission for AHF

 3. Systolic blood pressure > 100mmHg, heart rate < 115bpm*

 4. Previous history of HF *Patients with atrial fibrillation but controlled HR are
 eligible

 For Caregiver Burden assessments. The eligibility criteria for a caregiver: 1) person
 either self-identifies, or when asked identifies themselves, as the primary caregiver for
 the patient. If there are multiple caregivers, the person who self-identifies as providing
 the most care will be asked to provide verbal informed consent.

 Exclusion:

 1. Transplanted organ of any kind or ventricular assist device patient;

 2. End stage renal disease, on dialysis, or eGFR < 20 mL/min;

 3. Acute coronary syndrome (e.g. EKG changes consistent with ischemia or troponin
 elevation secondary to ACS);

 4. Other acute co-morbid conditions (e.g. sepsis, altered mental status) that are
 unlikely to be treated within a SSU stay;

 5. Patients who require ventilatory support of any kind or intravenous
 vasodilators/vasopressor/inotropic support. Patients who receive a one-time dose of an
 intravenious vasodiolator, but are no longer on this medication, are eligible.

 6. Pregnant patients or any patient who has been pregnant in the last 3 months

 7. < 18 years of age

 8. Any patient who in the opinion of the clinician or investigator requires
 hospitalization or ICU level care or will require rehabilitation or skilled nursing
 after discharge from the ED or hospital

 9. Planned discharge from the emergency department

 10. Patients hospitalized within the last 30 days ONLY if the institution mandates these
 patients are observed. Otherwise these patients are eligible.

 11. De Novo (new Onset) AHF