Breaking the Law of Small Numbers
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See Article by Sax et al
I always avoid prophesying beforehand because it is much better to prophesy after the event has already taken place.
Over 50% of all hospital admissions originate from the emergency department (ED), supporting the popular belief that the ED admits too many patients. Although the ED is the source of most admissions,1 the truth is most patients seen in the ED actually go home. Of 141 million annual visits to EDs in the United States, only 12.6% result in admission.2 When it comes to acute heart failure (AHF), however, the perceived reality is in fact true. The ED admits ≈85% of patients who present with AHF, accounting for ≈80% of the >1 million AHF hospitalizations per year.3,4 Many patients with AHF clearly require acute care; but is it truly 8 of every 10 patients?
What do the data tell us? Unfortunately, little. Despite countless assertions that more patients with AHF should be sent home, supporting evidence is lacking.5,6 The most robust data come from our Canadian colleagues7,8; perhaps, we should simply extrapolate their data to the US setting. However, this highlights the surprising paucity of US data on outcomes of patients discharged from the ED with AHF. If we do extrapolate, current data suggest that patients discharged from the ED have worse outcomes than hospitalized patients!7 Our clinical gestalt to discriminate high from low risk seems poor.
Unlike chest pain and the rule-out risk-scores or risk-stratification instruments for acute coronary syndromes, no universally accepted tools exist for AHF.9 Several promising ED-based AHF risk instruments have been proposed both outside and within the United States8,9 but are not ready for prime time. They either (1) have …