Creating a Standardized Diuretic Order Set to Improve In-Hospital Diuresis

From the 2021 HVPAA National Conference

Avielle Movsas (Temple University Hospital), Evan Carabelli, Dharmini Shah Pandya, Alejandro Gonzalez, Meredith A. Brisco-Bacik, Avrum Gillespie

Background

Heart failure (HF) is the one of the main causes of hospitalization and readmission (1). It is important to properly diurese patients in the inpatient setting to prevent further decompensations and re-admissions soon after discharge. The DOSE-AHF study showed that only 15% of patients who underwent diuresis in the hospital were determined to be euvolemic when assessed afterwards (2).

Objective

We set out to determine how a standardized method of diuresis using an order set created in EPIC would impact length of stay (LOS) and number of days in ICU. Additionally, we wanted to determine whether this order set is utilized and useful in the hospital setting.

Methods

A multidisciplinary team at TUH, including cardiologists, nephrologists, hospitalists, pharmacists, and nursing, created a diuretic order set on EPIC based on the DOSE trial and current HF guidelines to standardize how to initiate and escalate diuresis. A retrospective analysis of 592 hospitalized HF patients at Temple University Hospital (TUH) between 12/2018-6/2019 was conducted and measured variables including whether diuretic order set was used, LOS index, and days in ICU. 82 patients were protocol patients and 510 patients were diuresed without the standardized order set. LOS index is defined as ratio of actual to expected LOS. Additionally, we looked at 1233 patients in 2020-2021 who were hospitalized with HF and analyzed how many times the diuretic order set was utilized. We also sent a survey to hospitalists and residents to determine if the order set is being used and reasons why the order set is underutilized.

Results

Using the 2019 data, the LOS index for patients in whom the order set was used was 1.01, versus 0.94 in non-protocol patients. The mean ICU days in protocol patients was 1.00 compared to 1.86 in non-protocol patients. From 1/2020 to 1/2021, there were 1233 cases of patients with HF diagnoses at TUH, but the diuretic order set was only ordered 85 times between 4/2020-4/2021.

Out of 33 survey responses, 84.5% were aware that EPIC has a diuretic order set but 66.7% of all respondents rarely/never use the order set. 48.5% replied that they do not use the diuretic order set since they “know how to diurese patients” and 18% were concerned about over-diuresing with the order set. Out of 16 resident respondents, 56% said that their attending physicians preferred a different diuretic dosing so the order set was not used. Inaccurate I/O (82%) and inaccurate daily weights (70%) were reported as an often/very often barrier for appropriate diuresis.

Conclusion and Clinical Implications

Preliminary data shows that utilizing a standardized diuretic order set was associated with decreased number of ICU days. Further analysis with a larger database is required to determine if LOS is affected by ordering the diuretic order set. It appears that improving accuracy of measuring I/Os and daily weights are needed to better diurese patients in the hospital. Additionally, improving those barriers would allow us to further analyze whether the diuretic order set impacts LOS and ICU days. Further education is needed to both inform house staff that there is a diuretic order set and to instruct on recommendations for initial diuresis.

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