Assessing the risks: How a new scorecard is helping emergency doctors better assess risk in heart failure patients

Heart attacks, or "heart failure", occur when the heart is not pumping blood as well as it should. Although heart failure is one of the top reasons for hospital admission in Canada, symptoms like shortness of breath, fatigue and weakness are also associated with other ailments. That means heart failure can be tricky to diagnose. And since there is currently no single, consistent way for doctors to assess, diagnose and treat heart failure, some patients who are at low risk of life-threatening events may be admitted to hospital unnecessarily. Meanwhile, other high-risk patients may be discharged and sent home, without receiving the urgent care they need.

For Dr. Douglas Lee, a professor of medicine and cardiologist, fixing the problem starts right in the emergency department.

"The cardinal symptom of heart failure is shortness of breath," he says. "If you can't breathe, most people will go to the emergency department. That's why our research focuses on emergency as the hub of the spectrum of care."

By analyzing data from hospitals to understand why people with heart failure get admitted, discharged or readmitted, Dr. Lee and his team are working to standardize processes and improve patient care. "Variation in care can significantly affect the outcome for a patient, and can be a matter of life or death," he explains. "So, we want to explore why variations exist and find ways to reduce them."

A rapid assessment tool can save lives

To help reduce these variations in care, Dr. Lee and his team have developed a simple diagnostic tool called the Emergency Heart Failure Mortality Risk Grade (EHMRG, nicknamed and pronounced "emerge").

Doctors can use this web-based tool to rate ten variables such as heart rate/pulse; the presence of chemical compounds like creatinine, potassium and troponin; and other risk factors like an active cancer and if the patient arrived by ambulance. Since the tool was designed to draw on information available in the patient's clinical chart, it only takes about two minutes to complete. The resulting score produced by the EHMRG helps pinpoint the severity of the patient's illness and calculates their risk of heart failure-related death within seven to 30 days.

"The physician's eye, in general, is pretty good," says Dr. Lee. "But decisions in the emergency department must be made quickly, and often without advanced imaging. Sometimes patients look healthier than they really are, and vice versa, so our goal was to create a reliable and low-cost tool that could help."

Initial prospective studies, which took place in nine Ontario hospitals, allowed Dr. Lee's team to evaluate the tool's calculations by tracking the risk scores and real-life outcomes for nearly 2,000 patients. "We found that the EHMRG was very good at identifying both low- and high-risk patients," he explains. "And establishing this level of accuracy was important because we want emergency doctors to have confidence in the tool. The EHMRG is not meant to replace clinical judgement, of course, but it may help doctors make more informed decisions."

The trials also gave Dr. Lee's team the chance to compare the clinical assessments from emergency doctors against the mathematical risk rating from the tool. The results revealed that there was a tendency for physicians to overestimate the probability of seven-day mortality in low-risk patients and underestimate the probability in those at the highest risk. In other words, some low-risk patients were being hospitalized while some high-risk patients were being sent home.

Widespread use of the EHMRG tool has the potential to reverse those trends, which has clear potential to benefit patients and the health care system overall.

Exploring new ways to improve patient care

Doctors working in the emergency are trying to make the best decisions for their patients, and sometimes patients are being hospitalized because it is assumed that it will lead to the best care. However, sometimes, low-risk heart failure patients were being hospitalized as well.

"There are many reasons why doctors admit patients rather than discharge them," he explains. "These include the ability of patients to care for themselves at home, mobility concerns, other active medical issues, and the availability of social supports in the community."

When options therefore seem limited, hospital admission may look like the best choice. Patient concerns and preferences can also factor into the decision, so the result is that a patient can be admitted when (strictly speaking) hospital admission is not necessary. And the ugly truth is that there is a cost to the health care system for every patient hospitalized.

That said, Dr. Lee is quick to emphasize that patient-centred care and decision-making should not be sacrificed solely for cost savings. "As a clinician, your primary responsibility is to the patient," he says.

The trick then becomes designing a care model that can provide an appropriate "next step" for low-risk heart failure patients that will keep them out of the hospital – but will also provide timely and efficient care. With a controlled clinical trial called the Comparison of Outcomes and Access to Care for Heart failure (COACH), Dr. Lee's team is aiming to bridge that gap. In the lead-up to the COACH trial, the team developed a Rapid Heart Function clinic at the Toronto General Hospital. This specialized outpatient clinic serves low-risk heart failure patients for the first 30 days after their discharge from the emergency department.

In the COACH trial, staff will use an upgraded version of the EHMRG tool to assess eligibility for this new model of care in the Rapid Heart Function clinic. The new strategy will be compared to usual care, so the team will gain insights into whether patient outcomes with the clinic model are better or worse than the current care models.

The COACH trial, which began in 2016, is expected to see results later in 2022. If the clinic model works well, it could be scaled up to additional sites to prevent unnecessary hospitalizations for low-risk heart failure patients across Canada and prevent unwanted discharge of high-risk patients from the emergency department. Cost-savings aside, this could provide an option to reassure emergency doctors and patients that they'll be in good hands after discharge from the hospital.

"Our work is about trying to prevent premature mortality from heart failure, but we also want solutions that will help maintain the integrity of the universal health care system," says Dr. Lee. "This type of research lets us marry those worlds and can lead to sustainable care practices that work better for patients and the health care milieu."

Date modified: