Immediacy of follow up for a newly identified CCF? | Figure 1

Immediacy of follow up for a newly identified CCF?

Background:

One of the biggest challenges of practising as a paramedic in my area (UK) is formulating the most appropriate management plan for patients; the hospital that I transfer the vast majority of my patients to is under significant strain which frequently leads to substantial waiting times for patients. To put this into perspective, I recently waited outside of the ED for 6 and a half hours with a patient before there was space for them. As you can imagine, if patients are waiting this long simply to enter the hospital, the wait times inside are similarly protracted. We are encouraged to consider 'alternative pathways' and I feel this is particularly relevant to the demographic of patients with frailty for whom a prolonged stay in an ED is often detrimental to their wellbeing.

N. B. I do not have follow up for this patient, this is mainly a question to other EMS providers and Emergency/Acute Medicine clinicians as to the most appropriate management for this patient.

Case:

PC - 88 year old male presented with a fall from bed.

HPC - This patient was discharged home the day before his presentation to me following a 7/52 admission after a fall and #humerus. At around midnight he had leant out of bed (quite low to the ground) to pick up a urinary bottle from the floor; in doing so he slid out onto the floor and was unable to get up. His wife contacted EMS immediately for assistance.

OE - This patient was uninjured, had a good account of the events and after assistance from the floor was able to mobilise as usual (mildly decreased in comparison to his pre-admission mobility) using a walking aid. He reported no recent illness, felt generally well and all vital signs were unremarkable. Aside from the recent # his PMH was minimal, he was medicated with an ACE-inhibitor for HTN and took a variety of nutritional supplements (no recent changes).

As part of our local procedure I performed an ECG. The findings of which were consistent with LVH (axis & amplitude based on SL criteria and LV strain pattern). No other significant changes. This prompted me to perform a CV assessment which found a coarse pansystolic murmur (grade 3), heard best at the aortic point, which radiated to the carotid arteries. There was also coarse bibasal crackles with dull percussion over these areas. JVP was not increased and there was no peripheral oedema.

The patient denied any recent cough, breathlessness, orthopnoea, night sweats, chest pain, syncope/presyncope. As previously stated, he felt well and was actually a little confused as to why I was taking so much interest in him. Understandably, he was very opposed to returning to hospital so recently after a long stay.

Plan -

My impression was that these findings reflected congestive heart failure, most likely due to aortic stenosis. Given that the patient was asymptomatic, his preferences and that it was the middle of the night, I felt that it was acceptable to discharge him at home with robust worsening advice for follow up later that day (in-hours) via a routine admission to the local acute medical unit (which to my understanding would involve echo, CXR and serum BNP). I discussed this with an out-of-hours GP who recommended an immediate ED admission.

Now undoubtedly ED is the 'safest' option, but given the context and patient preferences is it necessary and in his best interest?

I'm interested to hear from EMS/GP/Primary care providers as to how they would manage a patient presenting in this way and from clinicians who would receive this patient as to how they would manage his care.