Background: Acute decompensated heart failure exacerbations remain a leading cause of morbidity and mortality and are associated with high rates of admissions and healthcare cost. Both the initial dose of intravenous (IV) diuretic and time to administration affect inpatient outcomes. Adequate diuresis prior to discharge is associated with a reduced likelihood of readmission. As part of a broader effort to improve heart failure management at our hospital, this project explores current diuretic management at Thomas Jefferson University Hospital (TJUH) and provides a baseline to compare future intervention effects.
Methods: This is a retrospective chart review of 73 patients discharged in August 2024 from a Department of Medicine service at TJUH with heart failure requiring IV diuretics. Inclusion verification and data extraction were performed by manual chart review. Initial emergency department (ED) diuretic dose was compared to a goal quadrupling of the home diuretic dose or 20 mg of furosemide equivalent if diuretic naive. Door-to-diuretic (D2D) time was evaluated using the first ED vital time to diuretic administration time. Adequacy of diuresis was defined as the number of days the patient lost greater than 2 kilograms or had greater than 2 liters of net negative output after receiving an IV diuretic the same day. Additional markers of adequate diuresis, including weight change and hemoglobin/albumin concentration, were collected when available. Analysis was performed in Excel.
Results: Of the 73 patients reviewed, 28 patients (38%) received an IV diuretic from the ED team. Of these patients, there was considerable variability of dosing, though the average initial dose was 111% of goal (min: 10%; max 400%; SD: 104%). The average D2D time was 4.03 hours (min: 35 minutes; max 13.7 hours; SD 2.63 hours) with 2 (7%) doses being given at the goal of less than 60 minutes after presentation. Regarding ongoing diuresis during hospitalization, patients received 241 total days of IV diuretics. They reached the goal urine output or weight loss on 32% of these days. Regarding the adequacy of diuresis prior to discharge, 41 (56%) patients had a discharge weight that was below their admission floor weight, 17 (23%) patients had a discharge hemoglobin that was more concentrated than on admission, and 15 (21%) patients had a discharge albumin that was more concentrated than admission. The average percentage weight change was -2.6% (min: -24%; max: 9.7%; SD: 6.2%).
Conclusions: These data raise concerns about heart failure recognition at initial presentation, dose choice and time to initial dose. There was notable variability in the first ED dose despite the mean being reassuring, and there are opportunities to improve consistency of dose choice. Further, the D2D mean of 4.03 hours and 7% rate of D2D being less than 60 minutes compares poorly to the literature and is a clear opportunity for improvement. The hospital teams can likely be more aggressive in daily diuresis with only 32% of IV diuresis days reaching pre-defined diuresis adequacy based on weight loss and diuresis-associated hemoconcentration. Our hospital teams can reduce readmission risk and improve outcomes by further diuresing patients prior to discharge. We will use these data for targeted systems interventions and as a baseline to compare the efficacy of these interventions to improve patient care and decompensated heart failure outcomes.