On March 5, 2025, The Hospital for Sick Children (SickKids) received a significant breakthrough in pediatric research with an $11.7 million award from Genome Canada. As part of the Canadian Precision Health Initiative, a total of $81 million in...
The Emergency Heart Failure Risk Mortality (EHMRG) Score
Heart failure patients are often admitted to hospital from the emergency department (ED) – it’s one of the world’s top causes of hospitalization.
However, it can be challenging for EM physicians to know who needs immediate care and who can be safely sent home. The Emergency Heart Failure Mortality Risk Grade (EHMRG) Calculator helps better identify heart failure patients who are stable and those in need of additional hospital care.
Listen to Dr. Douglas Lee, creator of the EHMRG Calculator, and Dr. Erin O’Connor, Division Director of Emergency Medicine at the University of Toronto, and other care providers discuss how EHMRG can effectively support decision-making in the emergency department. The video details:
- What the score is
- When the score should be used
- How the score is calculated
- Why the score is a valuable tool in emergency departments
The EHMRG score uses values and patient characteristics routinely collected on arrival to an ED and generates a risk score personalized to that individual. It helps the EM physician in their decision-making by providing a 7- and 30-day mortality risk.
The EHMRG score has been successfully integrated into the University Health Network (UHN) emergency departments using Epic’s electronic medical reporting system.
Further, the EHMRG calculator is now available for use by cardiologists and emergency medicine physicians in EDs across Canada via a web-based calculator.
Access guides and tools below to support the implementation of EHMRG in your ED – and reach out for additional advice and perspectives!
Explore the Toolkit
Case Study:
Implementing EHMRG at UHN
Curious about how the UHN emergency departments successfully integrated the EHMRG Calculator into their workflow?
Download the Case Study to learn about:
- The ED pathway design and components
- The role of the Integrated Care lead
- How EHMRG is generated and reviewed
- Impact on patient disposition decision-making
- Lessons learned and potential pitfalls to watch for
Implementation Checklist
This checklist outlines key considerations and question prompts for institutions looking to implement the EHMRG score.
It provides an overview of everything required to successfully bring the EHMRG score into your emergency department, including:
- Workflow considerations
- Technical considerations
- Human resource considerations
- Education
- Communications
EHMRG Score Infographic
Download a quick guide to the EHMRG Score that can be used by clinicians in the emergency department. This infographic includes:
- Background information on the score
- Parameters needed to run the calculator
- Score interpretation guidelines
- Where and how to access the calculator
Podcast Episode – Acute Heart Failure Risk Stratification and Disposition
Listen to Drs. Douglas Lee and Claire Atzema discuss the challenges of heart failure in the ED and how the EHMRG score can help with Emergency Medicine (EM) Cases host Dr. Anton Helman.
Educational Rounds – Coming Soon!
The EHMRG score has been featured as a part of many educational rounds at hospitals across Ontario, increasing awareness of both the tool and patients with heart failure presenting in the ED. The EHMRG calculator is currently in discussion to be featured on CAEP National Ground Rounds this fall, with more details to follow.
If you’re interested in having the EHMRG score featured at rounds in your hospital, please reach out to Joann Varickanickal at joann.varickanickal@uhn.ca for more information.
The EHMRG Score Evidence
The EHMRG calculator was first designed to predict seven-day mortality— recommending admission for any heart failure patient whose risk of dying in one week reached a certain threshold. Building on the success of the 7-day algorithm, an updated version of the EHMRG calculator with a more complex risk grade capable of predicting 30-day mortality has since been validated.
Validation
The goal of the tool was to empower doctors to discharge low-risk patients quickly. This improves their quality of life, ensures resources for higher-risk patients, and saves significant health-care costs.
The tool also ensures high risk patients are appropriately admitted to hospital to stabilize their heart failure.
The EHMRG calculator is a tool that supplements clinical judgement with validated, objective estimates of risk t and, as a result, a more personalized approach to patient care. The risk calculator was first proven effective in a study published in Circulation in 2012, and was developed by Dr. Douglas Lee, the Ted Rogers Chair in Heart Failure Outcomes and a Senior Scientist at the Institute for Clinical Evaluative Science.
Effectiveness
Following initial success, a randomized trial in 10 Ontario hospitals with over 5000 patients (the COACH trial) compared usual emergency department care with the EHMRG score for managing acute heart failure. The results were promising: only 12.1% of patients in the intervention group experienced death or cardiovascular hospitalization within 30 days compared to 14.5% in the control group. The EHMRG score also showed an improvement in long-term outcomes over 20 months.
These findings provided support for integrating the tool into the EMR system at UHN, where it has been helping ED physicians manage heart failure patients ever since.
Partners & Acknowledgements
The Emergency Heart Failure Mortality Risk Grade (EHMRG) Calculator was created by a dedicated team of clinicians, scientists, staff to help improve the experience of patients with heart failure and physicians in the emergency department providing care.
The EHMRG Calculator and corresponding resources would not have been possible without:
- Dr. Douglas Lee – Founder of the EHMRG score, Cardiologist at the Peter Munk Cardiac Centre, and Chair in Heart Function Outcomes at the Ted Rogers Centre for Heart Research
- Dr. Heather Ross – Head of the Division of Cardiology at UHN, Scientific Lead of Ted Rogers Centre for Heart Research at UHN
- Dr. Erin O’Connor – Director, Division of Emergency Medicine at UHN
- Jesmilavathani Murusalin – Integrated Care Lead, Toronto General Hospital Emergency Department
- Dr. Suzanna Mak – Cardiologist at Mount Sinai Hospital, Steering Committee Member for COACH Trial
- Dr. Michael J. Schull – Chief Executive Officer at ICES, Steering Committee Member for COACH Trial
- Dr. Michael E. Farkouh – Cardiologist at Mount Sinai Hospital, Steering Committee Member for COACH Trial
- Anne Simard – Staff Scientist, Ted Rogers Centre for Heart Research
- Dr. Sam Petrie – CIHR Health System Impact Fellow, Ted Rogers Centre for Heart Research
- Samantha Engbers – Research Planning Associate, Ted Rogers Centre for Heart Research
- Samantha Li – Animator and Medical Communicator
Funding
Funding was generously provided by the Ted Rogers Centre for Heart Research, Institute for Clinical Evaluative Sciences, and the Ontario SPOR SUPPORT Unit’s IMPACT award.
