IMPROVED: Implementation of Markers and Point-of-Care Ultrasound to Recognize Volume Overload in the Emergency Department

Acute decompensated heart failure (ADHF) is a leading cause of adult hospitalizations, yet bedside diagnosis remains imperfect. Objective tools such as laboratory tests, radiography, and point-of-care ultrasound (POCUS) improve diagnostic accuracy in ADHF. We aimed to characterize the demographic, diagnostic, and social determinants of health (SDoH) correlated with missed emergency department (ED) ADHF diagnosis.

We performed a retrospective cohort analysis of adult ED visits (≥18 years) with ADHF-suggestive chief complaints during 2023-2024 at a large integrated health system with 9 EDs and over 500,000 annual visits. Patients with an ADHF diagnosis (ICD-10 I50.x) in the ED, observation, or inpatient hospitalization were included, and 72-hour return visits were examined for patients discharged from the ED. Patients with ADHF were categorized by diagnostic outcome (correct vs missed ED diagnosis). Demographic variables, clinical biomarker orders, POCUS performance, and SDoH including age, sex, race, ethnicity, and primary spoken language were analyzed and compared between the diagnostic cohorts. Multivariate logistic regression was used to evaluate the associations between SDoH, medical history, and in-ED workup with diagnostic outcomes.

Among 10,099 visits for ADHF (1.2% of all visits), 1,980 (19.6%) received missed ED diagnoses. The two most impactful clinical factors correlated with ADHF diagnostic accuracy were whether a B-type natriuretic peptide (BNP) was ordered (OR of missed ADHF diagnosis 0.46, 95% CI [0.26, 0.83], p = 0.01) and POCUS performed (OR 0.27, 95% CI [0.13, 0.59], p = 0.001). Heart failure history reduced missed diagnosis risk (OR 0.46, 95% CI 0.41-0.52, p

BNP testing and POCUS significantly improve diagnostic accuracy for patients presenting to the ED with ADHF. Patients with overlapping cardiopulmonary conditions face higher risk of misdiagnosis. Further work is needed to investigate whether standardizing diagnostic workflows to incorporate objective diagnostic tools improves diagnostic accuracy for ADHF.