Background: Over 6.5 million Americans aged 20+ live with heart failure (HF) which is one of the most common reasons people age >65 are admitted. 2017 an estimated 924,000 patients resulted in 1.2 million HF admissions (26% increase from 2014). HF results in frequent re-hospitalizations, prolonged LOS with the CDC estimating (2012) cost of care at $30.7 billion. Thus, a ED RN driven pathway was developed and launched system wide on 10/20/2025 to ensure rapid and adequate diuresis in the first 6 hrs of presentation to the ED in hopes of improving patient care with rapid decompression of acutely decompensated patients.
Purpose: Rapid Effective Diuresis (RED) pathway is a RN driven order set intended to be primarily utilized in the ED ensuring appropriate diuretic doses are administered in the first 6 hrs of presentation. Built into our electronic ordering system, RNs follow a stepwise ordering of 2 doses IV diuretics based upon a urine sodium value ensuring adequate and effective naturesis and diuresis in the first 6 hrs. The goal is to reduce LOS and improve quality care by ensuring rapid ED diuresis. This pathway aims at reducing delay in patient care and avoiding missed doses due to ED volume or provider hand offs. The pathway can be continued on the floor without interruption with the admission orders. Recording of urine output in the ED is not required to guide diuretic dosing as we use a urine sodium level to ensure effective naturesis reducing RN burden and allowing for systematic dosing. Preliminary data confirms widespread use across the entire health care system. No adverse events have been reported. Preliminary data suggests that few patients were even able to avoid admission and be safely observed or discharged directly from the ED. As we continue use of this pathway, we will be evaluating LOS, adverse outcomes, and work on an expansion of the order set to expand into the 1st 24-48 hours of inpatient stay.
Description: The Rapid Effective Diuresis (RED) RN driven pathway was designed to reduce delay in second administration of IV diuretic in our acutely decompensated HF patients. Studies have shown that delay in rapid diuresis increases LOS and can lead to poor patient outcomes such as escalation to ICU level of care. In the ED it is very challenging to monitor strict I&Os. Using a urine sodium withing 2 hours after the initial dosing of the 1st IV diuretic allows the team to know if naturesis and diuresis has been achieved or if an escalating dose is required. Given our institution use of a urine sodium level of 70 or higher signifying adequate diuresis, a nurse driven electronic medical record order set was able to be developed to allow the RN to rapidly give the 2nd IV diuretic dose no longer than 6 hrs after the 1st dose. This reduces the time lag between provider ordered doses which can be over 12 hrs in some cases to ensure patients are receiving adequate diuresis early in their ED stay.
Conclusions: RED went live across the health care system 10/25/2025. In the 1st month, it was ordered 281 times. 0 recorded adverse events for patient safety. 30 patients were able to be downgraded to obs status. 9 patients were able to achieve adequate diuresis and discharged from the ED. It relies on an objective urine sodium value of 70 or higher to guide the second dose of IV diuretic without having a delay in provider ordering and guaranteeing multiple IV doses are able to be administered in a defined period of time (currently 6 hours). We expect given the literature, this will continue to improve patient outcomes and reduce LOS.