EHMRG SCORE STUDY version 6.2; date: 11Jul11 PI: Dr. Douglas Lee. Study Background

Transcription

1 EHMRG SCORE STUDY version 6.2; date: 11Jul11 PI: Dr. Douglas Lee Study Background Heart failure (HF) is a leading cause of morbidity and cardiovascular mortality. The burden of HF has increased over time to become one of the leading reasons for emergency department visits, hospitalization, and physician visits. In Canada, there are ~85,000 patients with HF admitted to hospital, representing a total of ~1.38 million hospital days. In the United States, Emergency Department (ED) visits have increased over time and exceed ~1 million HF visits per year. HF will likely have an even greater burden on health care in the future because the lifetime risk of HF in men and women is 1 in 5. There are presently ~8 million Canadians aged 55 years, among whom over 1.6 million may already have or will develop HF in the future. HF patients are frequently in contact with acute care hospitals (>19,000 ED visits per year for HF in Ontario). Yet there are no currently available tools to help decide on prognosis in HF patients who present to the ED and thus guide physician decision making in the ED. This has been demonstrated in prior work, where we have found that the risk of patients who are admitted overlap substantially with those who are discharged from the ED. 4,000 Number of Patients 3,500 3,000 2,500 2,000 1,500 1,000 Admitted Discharged We have found in prior work that there is significant variability in the prognostic profiles of patients who are discharged or admitted from the ED. The decision to discharge from the ED may be based on clinical improvement after initial treatment in the ED, yet the National Ambulatory Care Reporting System (NACRS) database in Ontario reveals that among HF patients who are discharged from the ED 1.2% die within 7 days and ~4% die within 30 days post-ed discharge. Including patients who are discharged and admitted, overall mortality at 7 days is 2%. Episodes of acute HF indicate an exacerbation of symptoms that funnel towards the final common pathway of acute care in the ED. Critical decisions in the emergent care of acute - 1 -

2 HF need to be made accurately and quickly, and could be guided by predictive decision tools. However, validated predictive tools for determining the early risk of HF death or morbidity in all ED patients are not available, and as a result, many HF patients discharged from the ED have high rates of adverse events. We have developed a HF risk score that predicts mortality at 7 days when applied to patients presenting to the ED the Emergency Heart failure Mortality Risk Grade (EHMRG). In this study, we will aim to test the EHMRG risk tool for HF patients in the ED. STUDY PROTOCOL Inclusion Criteria: Patients 18 years of age or older with a valid health card number Patients with heart failure or suspected heart failure as per the Framingham Criteria (see below) Framingham criteria for heart failure Major criteria Paroxysmal nocturnal dyspnea Orthopnea Jugular venous distension Hepatojugular reflux Pulmonary rales Radiographic cardiomegaly Acute pulmonary edema Third heart sound Central venous pressure >16 cm Weight loss >4.5 kg during first 5 days of treatment Minor criteria Bilateral ankle edema Nocturnal cough Dyspnea on ordinary exertion Hepatomegaly Pleural effusion Heart rate >120 beats per minute * Heart failure adjudicated present if two major or one major plus two minor criteria present Exclusion Criteria: Palliative patients or patients with a DNR (do-not-resuscitate) on the chart. End-stage renal disease on dialysis Instructional Page for Calculating the EHMRG Score (UHN) 1. Open the EHMRG File Folder 2. Open the blank fillable PDF - Current version is v6.2, date 11Jul11-2 -

3 3. Select Reset Form to clear the form from any previous responses. 4. In the PDF, enter the Patient information in the space provided: a. Medical Record Number (MRN) b. Date of ED visit (dd/mm/yy) c. Physician ID Enter your initials in the space provided. d. If a nurse has completed the form on behalf of a doctor, enter the nurse initials in brackets beside the physician id (e.g. ABC (DEF) where ABC is the MD and DEF is the nurse). 5. Complete the Pre-Risk Calculation Survey. All questions must be answered in order to obtain the score. PRE-RISK CALCULATION SURVERY 1 Was furosemide (or other loop diuretic) provided in the ED? 2 Did the patient improve with treatment? 3 Physician s estimated risk of 7-day death (singlechoice answer for questions a and b): DATA ENTRY Indicate if furosemide (or other loop diuretic) was provided in the ED Select Yes if furosemide (or other loop diuretic) was provided in the ED Select No if furosemide (or other loop diuretic) was not provided in the ED Indicate if the treatment of furosemide (or other loop diuretic) provided in the ED improved the condition of the patient. Select Yes if the patient improved with treatment. Select Uncertain if you are not sure if the patient has improved with treatment. Select No if the patient did not improve with treatment or if furosemide (or other loop diuretic) was not provided in the ED. See below A graph has been included to show the Ontario benchmarks 7-day death for heart failure patients 3a % probability Please provide your estimate of this patient s probability of death in the next 7 days as a % probability. Enter number from 0 to 100% in the space provide (NB: average 7- day mortality rate ~2%). 3b By category Please provide your estimate of this patient s probability of death in the next 7 days by category: Select Very Low Select Low Select Intermediate Select High Select Very High 4 Plan for patient? Indicate your plan for the patient: Select Discharge Home if you plan to discharge - 3 -

4 4b If patient is discharged, what type of follow-up would you suggest? 4c If patient is admitted, where would you prefer admission to? 5 What do you think is likely to happen to the patient? the patient. Select Admit to Hospital if you plan to admit the patient. Select Refer to Specialist Probable Discharge if you plan to refer the patient to a specialist and you expect that the specialist will discharge the patient. Select Refer to Specialist Probable Admission if you plan to refer the patient to a specialist and you expect that the specialist will admit the patient. Select Other if your plan for the patient is not listed above. Enter your plan in the space provided. If the patient is discharged, indicate what type of followup you would suggest for the patient: Select Family Physician if you would suggest the patient follow up with their family physician. Select Cardiologist if you would suggest the patient follow up with a cardiologist. Select Heart Failure Clinic if you would suggest the patient follow up with a heart failure clinic. Select Internal Medicine Clinic if you would suggest the patient follow up with an internal medicine clinic. Select None if you would not suggest any follow up or if the patient will be admitted. If the patient is admitted, indicate where you would admit the patient to (please note that this is not where the patient will be admitted to, it is where you would prefer to admit the patient to): Select Ward without Telemetry if you would admit the patient to the ward without telemetry. Select Ward with Telemetry if you would admit the patient to the ward with telemetry. Select Stepdown Unit if you would admit the patient to the stepdown unit. Select Intensive Care if you would admit the patient to intensive care. Select N/A if the patient will be discharged. Indicate subjectively what you think will happen to the patient: Select Will be Discharged if you think the patient will be discharged. Select Will be Admitted if you think the patient will be admitted. Select Social Admission if you think the patient will be admitted as a social admission. Select Do Not Know if you are uncertain what will - 4 -

5 happen to the patient. 6. Enter the required information for the risk variables based on the information available in the medical chart. Items 1 to 10 are required to calculate the score. Item 11 is optional. RISK VARIABLE DATA ENTRY 1 Age Enter the age of the patient in years. 2 Arrival by ambulance Indicate how the patient arrived to the ED. Select Yes if the patient arrived by ambulance to the ED. Select No if the patient did not arrive by ambulance to the ED (e.g. if the patient brought themselves to the ED or was brought by a nonparamedic individual). 3 Triage SBP Enter the first available systolic blood pressure measurement in mmhg. Only value from 1 to 300 will be accepted. 4 Triage heart rate Enter the first available heart rate measurement in bpm. Only value from 1 to 300 will be accepted. 5 Triage O2 sat: Enter the lowest value for the patient s O 2 saturation. The lowest value recorded should be entered for this value and does not need to be the first recorded value (if multiple values are recorded). Ideally, this value has been recorded within the first hour however values after the first hour should be considered and recorded if significant (e.g. a patient had an O 2 saturation of 95% upon arrival to the ED. After 1.5 hours, the patient s O 2 saturation had dropped to 87% and the patient was placed on O 2. 87% or 0.87 should be entered in the space provided for this parameter). If the lowest value recorded was taken by the paramedics, enter this value in the space provided instead of the value recorded by the triage nurse. Only value from 1 to 100 will be accepted. 6 Potassium concentration Enter the potassium (K + ) value documented after arrival to the ED Select <4.0 if the K + value was under 4.0 mmol/l Select 4.0 to 4.5 if the K + value was 4.0 to 4.5 mmol/l Select >4.5 if the K + value was over 4.5 mmol/l Select not done if no K + value was obtained. 7 Creatinine concentration Enter the first available creatinine concentration in µmol/l. Only value from 1 to 1000 will be accepted. 8 Troponin Enter the Troponin I or Troponin T (TpI or TpT) value - 5 -

6 recorded in the ED. If more than one value was reported, select the highest of the values obtained. Only value from 0 to 1000 will be accepted. In addition, to entering the numeric value for Troponin: Select elevated/above upper limit if the Troponin value was elevated above the upper limit (for probable and possible cases). Select normal if the Troponin value was not elevated or below the upper limit (negative results). Select not done if no Troponin value was obtained. 9 Any active cancer Indicate whether the patient currently has active cancer. Select yes if: o the patient has active cancer. o cancer is diagnosed in the ED. Select no if: o the patient s cancer has been treated successfully (e.g., cured or in long-term remission). o the patient has no history of cancer. Select unknown if you are unable to determine if the patient has cancer. 10 Using metolazone at home 11 Additional field: BNP measured? Indicate if the patient was prescribed metolazone prior to the arrival in the ED. Do not select yes if the medication was administered in the ED or in the hospital. Select yes if the patient was prescribed metolazone prior to the arrival in the ED. Select no if the patient was not prescribed metolazone prior to the arrival in the ED. OPTIONAL QUESTION Indicate whether brain natriuretic peptide (BNP) level was recorded during the ED visit Select Yes if BNP value was obtained. o If yes is selected, enter the BNP value in the space provided. Select No if BNP value was not obtained. 7. Upon completion of all the variables, select the Show Auto calculation button and the score will be displayed. 8. Select the Show Graph button and the chart diagram for the Risk of Death will also be displayed. 9. Select save as under the file dropdown menu to save the PDF for data transfer. Save the PDF using the following format: EHMRGXX_XXXX.pdf a. EHMRG b. First 2 XX: Doctor s 2 digit number (as provided) - 6 -

7 c. Last 4 XXXX: Last 4 digits from the MRN for each patient. Please note that this information needs to be distinct for each patient. * Please note that this is a pilot study and decisions to admit or discharge should not be based on the score provided. This information is being collected for information purposes only