Title: Evaluation of Diuretic Administration in Admitted Congestive Heart Failure Patients via the Emergency Department
Abstract: Purpose: Appropriate diuresis in congestive heart failure patients is important for overall outcome of the disease. The most frequent cause of hospitalizations is due to congestion, which can be alleviated by the use of diuretics if started at an appropriate time. Failure to do so can increase cost, length of stay, and morbidity. The primary objective of this study was to determine whether the first dose of diuretic was ordered and administered timely in the emergency department (ED). The secondary objective was to assess time to diuresis (in minutes) and the total urine output (in mL) in the first twelve hours. Methods: The Institutional Review Board approved this retrospective chart review that was conducted using patients with the diagnosis of congestive heart failure from January 1, 2016 to July 31, 2016. Patients 18 years of age or older, male or female, and who have been given a diuretic within the first 24 hours of admission were evaluated. The electronic medical record system was used to collect the following data: patient age, gender, length of stay, home diuretic dose, past medical history, time of ED arrival, diuretic ordered, time ordered and administered, and time to diuresis. All data was de-identified and remained confidential. Dosage and timing of when diuretic was ordered, time to diuresis from administration, and amount of diuresis (in mL) were assessed as final outcomes. Descriptive statistics were used to analyze all data collected in this study. Results: A total of 325 patient charts were analyzed to include a final number of 100 charts in this retrospective study analysis. The average time to diuretic order from ED arrival was approximately 200 minutes. About 43% patients were ordered furosemide 40 mg as first diuretic. The average time to first diuresis from diuretic administration was 290 minutes. Average urine output in the first 12 hours was 1167 mL. Conclusion: From this 100 patient chart assessment, it can be concluded that increased time to diuretic order from ED arrival and suboptimal initial diuretic dosage may have an impact on the amount a patient is able to diurese. This conclusion aligns with previous studies which showed an effect on patient outcomes. Currently, this data is being used to actively evaluate prescribing practices and a multidisciplinary team has been created with ED physicians, cardiologists, clinical pharmacists, nurses, department directors, and cardiology chairmen to discuss the next steps needed to optimize diuretic dosing. From this multidisciplinary team meeting, initial diuretic dosing orders in the ED will be changed from the average dose of furosemide 40 mg IV daily to furosemide 80–100 mg IV daily depending on patient specific parameters. Future directions will evaluate the impact this study had to our practice and how these implemented changes will ultimately affect patient outcomes and lengths of stay.