CHF Observation Unit

Aka: CHF Observation Unit, CHF Emergency Department Observation Unit, Congestive Heart Failure EDOU

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II. Indications: Observation Unit Admission

  1. Known Heart Failure AND
  2. Moderate Severity CHF Exacerbation
    1. Orthopnea, Dyspnea on exertion or Shortness of Breath at rest
    2. Lower Extremity Edema
    3. Weight gain
    4. Pulmonary rales
    5. Jugular Venous Distention
  3. Identifiable trigger for exacerbation is often present
    1. MIssed Diuretic dosing
    2. Excessive dietary salt intake

III. Contraindications (Admit to hospital instead of Observation Unit)

  1. Unstable Vital Signs
    1. Persistent Hypotension (systolic Blood Pressure <100 mmHg)
    2. Uncontrolled Hypertension requiring intravenous infusion (i.e. Hypertensive Emergency)
    3. Tachycardia persistent and refractory to initial emergency department management
  2. New Lab abnormalities
    1. Serum Troponin newly increased or new EKG ischemic changes
    2. Hyponatremia
    3. Acute Kidney Injury (e.g. Serum Creatinine >3 mg/dl, BUN>40 mg/dl)
  3. Other observation exclusion criteria
    1. New onset Congestive Heart Failure
    2. Unstable Angina
    3. Acute comorbidities requiring >48 hour inpatient hospital stay (e.g. severe Pneumonia)
    4. Altered Mental Status
    5. New Hypoxia
    6. Non-Invasive Positive Pressure Ventilation (e.g. BiPap)
    7. Fever

IV. Management

  1. See Congestive Heart Failure Exacerbation Management
  2. Diuretics
    1. Initial Diuretic management in Emergency Department
      1. Start with intravenous Diuretic dose that is double the home oral dose
      2. Furosemide 60 mg IV is often used as an initial default IV dose
    2. If Urine Output <400 ml in the 4 hours following initial Diuretic dose
      1. Give a second intravenous Diuretic dose at twice the initial IV dose
    3. If Urine Output >400 ml after first or second Diuretic dose
      1. Transition to intravenous Diuretic at optimized dose twice daily
  3. Monitoring
    1. Daily Weights including baseline weight recorded at Emergency Department presentation
    2. Continuous Pulse Oximetry
    3. Telemetry
    4. Vital Signs every 4 hours
    5. Basic chemistry panel (e.g. Chem8) every 6 hours
      1. Obtain initial comprehensive panel on ED presentation to evaluate for hepatic congestion
  4. Hospital inpatient admission criteria
    1. Inadequate diuresis or symptom improvement at 24 hours
    2. Laboratory abnormalities
      1. Worsening Hyponatremia
      2. Significant Acute Kidney Injury (e.g. Serum Creatinine >3 mg/dl, BUN>40 mg/dl)
  5. Education
    1. Record daily weights on the same scale
    2. Low Sodium Diet (<2-3 grams daily)
    3. Overall fluid restriction (<2 Liters per day)
  6. Disposition
    1. Goal discharge within 24 hours (<48 hours)
    2. Patient symptom improvement is a key discharge marker
      1. Patient may lie supine without significant Orthopnea
      2. Ambulates without Light Headedness, Dizziness or Chest Pain
      3. Improved Dyspnea on exertion
      4. Baseline comfort on ambulation
    3. Vital Signs stable
      1. Resting Heart Rate <100 bpm
      2. Systolic Blood Pressure >90 mmHg
      3. Oxygen Saturation >90% (at baseline FIO2 requirements if on home oxygen)
    4. Follow-up appointment
      1. Primary care or cardiology follow-up within 1 week of discharge

V. References

  1. Busman and Pasternak (2025) Crit Dec Emerg Med 39(7): 4-13
  2. Collins (2015) J Card Fail 21(1):27-43 +PMID: 25042620 [PubMed]
  3. Fermann (2010) Curr Heart Fail Rep 7(3):125-33 +PMID: 20625946 [PubMed]
  4. Savioli (2020) Medicina 56(5):251 +PMID: 32455837 [PubMed]

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