Background: Rapid dosing of adequate intravenous diuretics for heart failure (HF) exacerbations saves lives; specifically, a door-to-diuretic (D2D) time < 60 min had an odds ratio of 0.39 for inpatient death. As part of a hospital-wide push for improved heart failure management, baseline D2D time was measured in August 2024, showing an average of 4.03 hours and suboptimal dosing ratios. In addition to a one-off caregiver education initiative and financial incentives, electronic tools, including an order set/panel with clinical decision support systems (CDSS) and guiding language emphasizing lower D2D and appropriate dosing were implemented in November 2024. This project’s aim is to evaluate preliminary May 2025 post-intervention data, assess electronic tool adoption, establish benchmarks for automated tracking, and identify barriers to improve patient outcomes.
Methods: Manual chart review was conducted on ED patients receiving IV loop diuretics at an urban academic hospital comparing baseline and post-intervention cohorts using several metrics: D2D time (hours from arrival to administration of an IV loop diuretic), dosing ratio (ED dose as a percentage of target dose, defined as 4x the home dose or 20 mg furosemide if not on a home diuretic), and electronic intervention usage (HF admission order set usage as a surrogate for ED HF panel, sharing a common diuretic guidance section). Baseline cohort was derived from department of medicine discharges given IV diuretic, with manual HF confirmation; post-intervention cohort from automated data identifying patients with a primary discharge diagnosis of HF. Analysis included descriptive statistics and exploratory unpaired t-tests for comparisons.
Results: Baseline August 2024 data showed D2D time of 4.03 hours (SD 2.63, n=73) and dosing ratio of 111% (SD 104%, min 10%, max 400%), while post-intervention (May 2025) revealed D2D time of 4.56 hours (SD 2.79, n=48) and dosing ratio of 132% (SD 71%, min 25%, max 300%) with no significant differences (D2D p=0.292; dosing p=0.224). HF Admission Order Set use was 10.4% (5/48).
Conclusions: Post-intervention data showed no reduction in D2D time or improvement in appropriate dosing, with low adoption (e.g., 10.4% for the HF admission order set, reflecting use at any point during hospitalization, not just ED use) indicating implementation barriers in ED workflows and clinician engagement with electronic interventions. Based on these findings, educational campaigns and deployment of order sets to improve D2D and dosing adequacy without high adherence or additional systems change are ineffective. There is some promise in the reduced SD in dosing ratio. Future steps include refining the intervention through EHR adjustments to improve adherence; assessing feasibility, impact, and sustainability of non-EHR systems change; expanding automated data for larger-scale monitoring and real-time feedback; and validation in larger cohorts as well as across disparate hospitals to assess for local effects.