RESUMO
BACKGROUND: Management of congestive heart failure (CHF) is dependent on clinical assessments of volume status, which are subjective and imprecise. Point-of-care ultrasound (POCUS) is useful in the diagnosis of CHF, but how POCUS findings correlate with therapy remains unknown. This study aimed to determine whether the changes in clinical evaluation of CHF with treatment are mirrored with changes in the number of B lines on lung ultrasound (LUS) and inferior vena cava (IVC) size. In this prospective observational study, investigators performed serial clinical and ultrasound assessments within 24 h of admission (T1), day 1 in hospital (T2) and within 24 h of discharge (T3). Clinical assessments included an evaluation of the jugular venous distension (JVD), hepatojugular reflux (HJR), pulmonary rales and a clinical congestion score was calculated. Ultrasound assessment included the IVC size and collapsibility, and the number of B lines in an 8-point scan. RESULTS: Fifty consecutive patients were recruited with a mean age of 71.2 years (SD 12.7). Mean clinical congestion score on admission was 5.6 (SD 1.4) and declined significantly over time to 1.3 (0.91), as did the JVP, HJR and pulmonary rales. No significant changes were found in the IVC size between T1 [1.9 (0.65)] and T3 [2.0 (0.50)] or in the IVC collapsibility index [T1 0.3 (0.19) versus T3 0.25 (0.16)]. The mean number of B lines decreased from 11 (6.1) at T1 to 8.3 (5.5) at T3, although this decrease did not reach statistical significance. Spearman correlation between JVP and HJR versus IVC collapsibility and total B lines did not yield significant results. CONCLUSIONS: Clinical exam findings correlate over time during the management of CHF, whereas LUS and IVC results did not. The number of B lines did decrease with therapy, but did not reach statistical significance likely because the sampled population was small and had only mild heart failure. Further studies are warranted to further explore the use of lung ultrasound in this patient population.
RESUMO
OBJECTIVE: To evaluate the ability of nurse clinician discharge flow coordinators (DFCs) to identify medical patients at risk of unplanned return to the hospital emergency department within 30 days of discharge and whether a higher predicted risk of return was correlated with preventability. DESIGN: Prospective cohort study of patients discharged from medical wards at 2 hospital sites of the McGill University Health Center between September 1, 2011, and January 1, 2012. METHODS: Univariate and multivariate analyses of factors including the ability of DFCs to predict 30-day unplanned returns to the hospital. Assessment of the preventability of returns to the hospital was performed by chart review using prespecified criteria. The ability of DFCs to predict returns was compared to the LACE criteria (length of stay, acute admission through the emergency department, comorbidities, and emergency department visits in the past 6 months). RESULTS: We found that 25.0% (95% CI, 21.3-28.5) of our patients returned to the emergency department within 30 days. The DFC predictions were found to be significant in both univariate and multivariate analysis. Patient age, sex, and length of stay were not significant predictors in univariate or multivariate analysis; 13.9% (95% CI, 8.2-19.6) of returns were preventable and a further 25.8% (95% CI, 18.1-33.5) were potentially preventable with added services in the community. There was a trend toward more preventable or potentially preventable returns with higher predicted probability of return. In contrast the LACE criteria did not have a good predictive capacity in our patient population. CONCLUSION: In a large urban center, experienced nurse clinician DFCs were able to predict 30-day emergency department returns with reasonable accuracy. They were also able to identify the returns to the hospital that were most likely to be preventable. Our data suggests that DFCs can be used to target patients identified as having an increased probability of return with interventions that may be able to reduce the burden of return to hospital.