From the 2024 HVPA National Conference
Brandon Temel MD (University of Michigan), Nelish Ardeshna MD (Rush University Medical Center), Joye Allen PharmD, MPH, Andrew Siler PharmD, BCPS, Malte Breitlow PharmD, Gabriel Solomon MD, Christopher Grondin MD
Background:
Heart failure carries significant morbidity, mortality, and economic impact. In 2018, nearly 5 million discharges included any congestive heart failure (CHF) code, with nearly 1.2 million carrying a primary diagnosis of CHF.³ These hospitalizations cost the US $35 billion annually.³ At the Veterans Affairs Ann Arbor Healthcare System (VAAAHS), patients with CHF have a length of stay (LOS) of 7.5 days, two days longer than national averages for CHF admissions. Inadequate diuresis contributes to extended LOS and readmissions, with VAAAHS patients receiving an average of 1.6 daily IV diuretic doses, below the American College of Cardiology (ACC) recommendation of at least twice daily dosing.²³
Objective:
The aim of this project was to increase the frequency of diuretic administration among CHF patients at the VAAAHS. We hypothesized that the integration of an order set into the electronic health record (EHR) would improve diuretic frequency to a goal of twice daily, in line with national recommendations.
Methods:
An order set was developed and integrated into the EHR, streamlining 2-3x daily diuresis with one-click automation. Included were ACC diuresis guidelines, electrolyte supplementation, and diuretic dose conversions. To promote use, each new general medicine resident team received an email, an in-person visit to discuss the intervention, and a follow-up email two weeks later. Team rooms additionally received printouts/advertisements. The order set was highlighted in resident education conferences at launch and after six weeks. Data from a 3-month period pre- and post-intervention was collected via chart review to determine average IV diuretic doses administered per day of diuresis for each patient. Inclusion criteria required CHF as admission diagnosis and >1 total IV diuretic dose during hospitalization. A two-tailed t-test compared the means of the groups. A post-study survey evaluated resident knowledge of diuresis guidelines, awareness and utilization of the order set, recommendations to increase awareness, and barriers to diuresis.
Results:
A total of 55 patients were included in the final analysis, 27 in the pre-intervention group and 28 in the post-intervention group. There were no statistically significant differences in the mean daily IV diuretic doses between the pre- and post-intervention groups (1.621 and 1.616, p = 0.96). Forty residents responded to the survey. 100% reported a preference for 2-3x daily diuretic dosing over 1x daily and 85% indicated that an automated order set would be helpful. Despite the intervention, only half of respondents were aware the order set existed. Of those that used it, 74% found it useful. Additional in-person teaching and integration into service documents were common suggestions to increase awareness. Insufficient charting of fluid intake and output data was reported as the biggest barrier to more frequent diuresis.
Conclusion:
While all surveyed residents aligned with national guideline recommendations regarding diuretic administration, our analysis revealed a disparity with actual practice. This disparity has substantial implications for LOS, readmissions, and cost. Despite our intervention, there was no impact on the metric of interest, though survey data inferred optimism regarding the utility of this order set, with actionable recommendations to increase use. Furthermore, additional barriers to effective diuresis were highlighted.
Clinical Implications:
Despite no observed increase in diuretic frequency, feedback regarding the practicality and efficacy of the order set was positive. Furthermore, the barriers identified create opportunity for further quality initiatives and highlight the importance of performing multiple Plan/Do/Study/Act cycles.