Clinical Characteristics Associated with Acute Heart Failure Dispositions and Outcomes from the Emergency Department

Abstract Background Acute heart failure (AHF) is a leading cause of Emergency Department (ED) attendance among older adults and contributes substantially to hospitalisations and resource strain. Globally, more than 80% of acute heart failure presentations to EDs result in inpatient admissions, despite wide variability in severity and risk of short-term adverse outcomes. Understanding AHF disposition patterns may be helpful for identifying opportunities to optimise care pathways. This study describes the clinical characteristics associated with ED disposition decisions for AHF and compares short- and long-term outcomes across discharge, ward admissions, and Higher Care Unit (HCU) admissions. Methods We conducted a retrospective cohort study using ED presentation data from a major Singapore public hospital between June 2016 and December 2021. Patients with SNOMED-coded heart failure diagnoses were included. Demographics, clinical presentation, comorbidities, and administrative factors were analysed. Primary outcomes were mortality, ED revisits, and readmissions at 30 days and one year. Multinomial logistic regression was used to examine factors associated with discharge versus ward or HCU admission. Results Among 3,723 AHF presentations, 4% were discharged, 87% admitted to the ward, and 9% to an HCU. The median age was 72 (62–81) years and 40.7% were women. Higher acuity, abnormal vital signs, multimorbidity, and myocardial infarction history were associated with HCU admission. Directly discharged patients had much higher 30-day ED revisit rates (31% vs 22% ward vs 19% HCU) but similar one-year revisit rates. One-year mortality was lower for discharged patients (13.5%) than for those admitted. Conclusion AHF patients present with complex clinical needs and are predominantly admitted in Singapore. However, high admission rates in the context of hospital overcrowding and ED bed block highlight an opportunity to develop structured alternative care pathways, such as observation units, transitional care, and home-based hospitalisation, to reduce unnecessary inpatient utilisation and improve continuity of care safely.