Guidelines for ED Observation of Congestive Heart Failure


  • Previous history of congestive heart failure
  • Acceptable vital signs: Blood pressure >100/60, Respiration rate <32, Pulse <130
  • Pulse-oximetry >80 on room air, correctable to >90 on oxygen
  • High likelihood of correction to baseline status within 24 hours — consider discussion with private medical doctor


  • Unstable vital signs
  • New onset congestive heart failure
  • Associated unstable angina, chronic obstructive pulmonary disease, myocardial infarction, sepsis, pneumonia, new murmur, confusion
  • Electrocardiogram changes
  • Severe anemia (Hemoglobin <8)
  • New arrhythmia
  • Respiratory failure, intubation


  • Telemetry Monitor System monitoring
  • Oxygen per respiratory guidelines
  • Serial exams, vital signs, electrocardiograms, cardiac enzymes, and pulse-ox checks
  • Medication — diuretics, vasodilators, ACE Inhibitors, inotropics (Consider stopping medications with negative inotropic effects)


Home — Acceptable vital signs

  • Return to baseline status
  • Pulse oximetry >90 on room air unless previously on home oxygen
  • Electrocardiogram unchanged from baseline
  • No chest pain or dyspneu at rest

Hospital — Worsening respiratory status

  • New electrocardiogram changes, arrhythmia, or ischemia
  • Persistent hypoxia, rales, dyspnea
  • Failure to return to baseline status within 18-hour timeframe


Source: William Beaumont Hospital, Royal Oak, MI.