News

By Kim Barnhardt

An innovative heart failure decision tool is at the “heart” of efforts to help emergency departments across Ontario.

Developed by a team led by University Health Network (UHN) cardiologist Dr. Douglas Lee, the Emergency Heart Failure Mortality Risk Grade (EHMRG) calculator estimates the 7-day and 30-day risk of death for patients with congestive heart failure who seek emergency care. Dr. Lee’s 15 years of work developing the EHMRG score culminated in the COACH trial, a pragmatic effectiveness trial. It received IMPACT Award funding from OSSU to engage patients in the study steering committee whose ideas contributed to the project.

The EHMRG score (pronounced “emerg”) is a validated, data-driven calculator created to help clinicians determine if it’s safe to discharge a patient from the ED or if they should be admitted to hospital.

“The EMHRG score is an important tool for clinicians as it helps doctors make better decisions about their heart failure patients who present to the emergency department,” says Dr. Douglas Lee, cardiovascular program lead at IC/ES and cardiologist at UHN’s Peter Munk Cardiac Centre. “In particular, it helps doctors decide if the patient is high-risk and might need to be admitted to hospital or whether they are low risk and can potentially be discharged home.”

Building on the success of the COACH trial, which was published in The New England Journal of Medicine and featured in CMAJ, and on successful integration of the tool at UHN, the team is now focused on knowledge translation (KT) activities to support uptake of the EHMRG score in Ontario hospitals. The COACH trial was one of the first studies that showed a reduction in hospitalization and death for heart failure patients. Currently, at least 12 Ontario hospitals are using the tool as well as three in the United States, which reached out to the team because of the COACH trial’s high-profile.

“The overarching goal is to support institutions across Ontario integrate the tool into emergency department work flow, with the KT tools to help,” says Anne Simard, Staff Scientist and Director of Strategy and Translation, Ted Rogers Centre for Heart Research (TRCHR) and TRANSFORM HF. “Several centres have asked for follow up and a few are interested in integrating into EPIC [the electronic medical records software used by many hospitals]. We are trying to create a snowball effect on the implementation side.”

To support the expansion of EHMRG across the province, Dr. Lee’s team interviewed centres using the tool to understand how it is being used, how to improve uptake, and ideas for knowledge translation materials, for which OSSU has provided funding. Four themes emerged: the need to generate awareness of the score in EDs, integration into existing processes and EMRs, education to help clinicians understand its utility, and communications to increase adoption and uptake.

To increase awareness of the EHMRG score, the team sought novel methods of dissemination. For example, the EHMRG score was discussed in the context of stratifying risk of HF patients on the popular podcast Emergency Medicine Cases in August with Dr. Lee and emergency medicine physician Dr. Clare Atzema. Additional KT efforts include a public website, infographic, video and related tools, partnering with the Canadian Association of Emergency Physicians (CAEP) on CAEP grand rounds, and follow up with interested hospitals. The team is also working with Ontario Health on a “best practice implementation” approach for heart failure programs and projects.  

They hope EMHRG will help lessen the burden on the health care system.

“Emergency departments are in crisis across Canada and there is a hierarchy of needs,” says Dr. Sam Petrie, a team member and CIHR Health System Impact Fellow, TRANSFORM HF. “In a perfect world, there would be a huddle and decision to discharge a patient but with no supports at home and multiple illnesses, they will be admitted, which is a wider system issue.”

The team acknowledges there are challenges to widespread expansion. With 12 EMRs in the province, differences in workflow in emergency departments compared with cardiology departments and understandable skepticism about another decision-support tool, there is plenty of work ahead. In addition, the decision-support tools must be adapted for use in EDs, each with different practices and processes. Having respected emergency physicians as champions, like Dr. Atzema and Dr. Erin O’Connor, is important for successful implementation.

“You really have to put yourself in the mindset of what is happening in an insanely busy environment –how do we make it easy for clinicians to make safe decisions?” says Anne Simard.

Ultimately, Dr. Lee and his team hope the EHMRG calculator will help busy EDs manage the ever-increasing patient flow to confidently discharge lower risk patients with outpatient follow up and support.

“COACH was significant as the burden on EDs is growing and the trial showed a reduction in meaningful ways that patients, clinicians and funders care about. This project demonstrates a way to integrate the tool on the front lines, moving from experimental research to clinician behaviour change, and ultimately applying evidence into every day practice,” says Dr. Lee.

To support their efforts to expand use of EHMRG, they are continuing outreach to rural hospitals and other health care professionals such as nurses and emergency department leads, research into integrating decision-making tools in the ED and evaluation of their activities.

“Most of our efforts are targeted at physicians but nursing would be the next layer,” says Dr. Lee. “We will also pursue heart failure physicians as they are on the receiving end of patients in clinics. We need to communicate with them too as not all hospitals were involved in the COACH trial so we want to include cardiologists as well.” Find the full suite of tools here.