J Clin Med Res

Journal of Clinical Medicine Research, ISSN 1918-3003 print, 1918-3011 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Clin Med Res and Elmer Press Inc

Journal website http://www.jocmr.org

Original Article

Volume 4, Number 6, December 2012, pages 402-409

Multidisciplinary Assessment to Personalize Length of Stay in Acute Decompensated Heart Failure (OPTIMA II ADHF)

Figure 1. Virtual triage algorithm. PACD: post acute care discharge score; SPI: “Selbstpflegeindex”. At all time points of risk assessment, medical risk has been evaluated first. In case of medical stability, biopsychosocial and functional risk (“2.”) was determined: if then the PACD-score (“2a”) was below 8 points, SPI was calculated (“2b”). Then, the virtual preferred site of care (according to the arrows) was explained to the patient, who could deny beeing discharged.

**Table 1.** Medical Stability Criteria
T: temperature; HR: heart rate; RR: respiratory rate; SO2: O2-saturation; pO2: partial pressure of O2; SBP: systolic blood pressure.
1. Marked reduction of most prominent admission sign (for example, dyspnea, edema, jugular venous distention, near complete resolution of rales)
2. Drop ≥ 30% of admission NT-proBNP
3. Stable oral medication and no i.v. therapy (diuretics, vasodilators, inotropics, vasopressors) for at least 24 h
4. Stable vital signs for at least 24 h (T < 37.8 °C, HR ≤ 100/min, RR ≤ 24/min, SO2 ≥ 90% or pO2 ≥ 60 mmHg on room air, SBP ≥ 90 mmHg)
5. Mental status back to baseline
6. No severe acute comorbidity necessitating hospitalization

Table 1. Medical Stability Criteria

T: temperature; HR: heart rate; RR: respiratory rate; SO2: O2-saturation; pO2: partial pressure of O2; SBP: systolic blood pressure.

1. Marked reduction of most prominent admission sign (for example, dyspnea, edema, jugular venous distention, near complete resolution of rales)

2. Drop ≥ 30% of admission NT-proBNP

3. Stable oral medication and no i.v. therapy (diuretics, vasodilators, inotropics, vasopressors) for at least 24 h

4. Stable vital signs for at least 24 h (T < 37.8 °C, HR ≤ 100/min, RR ≤ 24/min, SO2 ≥ 90% or pO2 ≥ 60 mmHg on room air, SBP ≥ 90 mmHg)

5. Mental status back to baseline

6. No severe acute comorbidity necessitating hospitalization

**Table 2.** Baseline Characteristics
No.: number; LVEF: left ventricular ejection fraction; data expressed as numbers and proportions or median and interquartil range unless stated otherwise.

Demographic characteristics	(n = 75)

Mean Age (years)	79.8
Sex (male), no. (%)	43 (57.3)

Coexisting illnesses, no. (%)

Cerebrovascular disease	5 (6.6)
Renal dysfunction	46 (61.3)
Pneumopathy	16 (21.3)
Malignancy	9 (12)
Diabetes	30 (40)
Peripheral artery disease	9 (12)
Any	71 (94.7)
Average count of coexisting illnesses	3.7

Anamnestic findings, no. (%)

Orthopnea	49 (65.3)
Paroxysmal nocturnal dyspnea	36 (48)
Palpitations	15 (20)
Cough	34 (45.3)
Nocturia	31 (41.3)
Gain of weight	21 (28)
Angina pectoris	9 (12)
Limited exercise capacity	63 (84)
Average severity of dyspnea (NYHA)	3.4

Clinical findings

Positive hepatojugular reflux (no./%)	49 (65.3)
Distended neck veins (no./%)	40 (53.3)
Lower extremity edema (no./%)	51 (68)
Rales (no./%)	53 (70.7)
Systolic blood pressure (mmHg)	129 (111 - 146)
Diastolic heart pressure (mmHg)	79 (68 - 89)
Heart rate (beats/min.)	92 (75 - 109)
Respiratory rate (breaths/min.)	20 (16 - 24)
Body temperature (°C)	36.7 (36.3 - 37.0)

Diagnostic findings

LVEF, if echo performed (50/75 patients) (%)	44 (30 - 65)
Radiologic congestion (no./%)	43/74 (58.1)
NT-proBNP (ng/L)	14,154 (4,261 - 17,057)

Table 2. Baseline Characteristics

No.: number; LVEF: left ventricular ejection fraction; data expressed as numbers and proportions or median and interquartil range unless stated otherwise.

Demographic characteristics

(n = 75)

Mean Age (years)

79.8

Sex (male), no. (%)

43 (57.3)

Coexisting illnesses, no. (%)

Cerebrovascular disease

5 (6.6)

Renal dysfunction

46 (61.3)

Pneumopathy

16 (21.3)

Malignancy

9 (12)

Diabetes

30 (40)

Peripheral artery disease

9 (12)

Any

71 (94.7)

Average count of coexisting illnesses

3.7

Anamnestic findings, no. (%)

Orthopnea

49 (65.3)

Paroxysmal nocturnal dyspnea

36 (48)

Palpitations

15 (20)

Cough

34 (45.3)

Nocturia

31 (41.3)

Gain of weight

21 (28)

Angina pectoris

9 (12)

Limited exercise capacity

63 (84)

Average severity of dyspnea (NYHA)

3.4

Clinical findings

Positive hepatojugular reflux (no./%)

49 (65.3)

Distended neck veins (no./%)

40 (53.3)

Lower extremity edema (no./%)

51 (68)

Rales (no./%)

53 (70.7)

Systolic blood pressure (mmHg)

129 (111 - 146)

Diastolic heart pressure (mmHg)

79 (68 - 89)

Heart rate (beats/min.)

92 (75 - 109)

Respiratory rate (breaths/min.)

20 (16 - 24)

Body temperature (°C)

36.7 (36.3 - 37.0)

Diagnostic findings

LVEF, if echo performed (50/75 patients) (%)

44 (30 - 65)

Radiologic congestion (no./%)

43/74 (58.1)

NT-proBNP (ng/L)

14,154 (4,261 - 17,057)

**Table 3.** Reasons to Overrule Triage Algorithm After Medical Stabilization
No.: number; CHF: congestive heart failure, data expressed as numbers and proportions.
Overruled cases total, no. (%)	32 (42.7)
Medical overruling criteria, no. (%)	3 (9.4)
Acute illness requiring hospitalization independent from CHF (no.)	3
Nursing and organizational overruling criteria, no. (%)	20 (62.5)
SPI-Index < 32 (no.)	3
Waiting for placement in a non-acute medical care facility (no.)	14
Other reasons (no.)	3
Patient's preferences, no. (%)	4 (12.5)
Concern about safety at home (no.)	2
Lack of supporting social network (no.)	2
No reason stated, no. (%)	5 (15.6)

Table 3. Reasons to Overrule Triage Algorithm After Medical Stabilization

No.: number; CHF: congestive heart failure, data expressed as numbers and proportions.

Overruled cases total, no. (%)

32 (42.7)

Medical overruling criteria, no. (%)

3 (9.4)

Acute illness requiring hospitalization independent from CHF (no.)

Nursing and organizational overruling criteria, no. (%)

20 (62.5)

SPI-Index < 32 (no.)

Waiting for placement in a non-acute medical care facility (no.)

Other reasons (no.)

Patient's preferences, no. (%)

4 (12.5)

Concern about safety at home (no.)

Lack of supporting social network (no.)

No reason stated, no. (%)

5 (15.6)