Published in the April 2015 issue of Today’s Hospitalist
GIVEN THE BURDEN associated with heart failure in U.S. hospitals “more than 1 million primary hospitalizations every year and the No. 1 culprit in 30day readmissions “you’d think that every aspect of inpatient heart-failure treatment would have been studied to death.
Surprisingly, that’s not the case. A new analysis that appeared in the February issue of the Journal of the American College of Cardiology: Heart Failure took the very first look at what most clinicians would agree must be a bad mix: treating heart failure patients simultaneously with both loop diuretics and IV fluids early in their hospitalization.
“We looked into something that was not even understudied “it was unstudied until our investigation,” says Behnood Bikdeli, MD, the study’s lead author and an internal medicine resident at Yale-New Haven Hospital in New Haven, Conn. “That, despite the fact that this may have a potential impact on patient outcomes.”
To most physicians, the combination just doesn’t make sense: Why give patients fluids when they’re already overloaded and you’re trying to get fluid off?
“It may be that as the use of EMRs becomes more routine, IV fluids are a part of order sets or EMR-driven recommendations,” Dr. Bikdeli notes, adding that the data used in the study were from 2009-10. Given that the use of electronic order sets is now more prevalent than it was then, “I’d guess that data now are either similar or maybe slightly worse.”
The retrospective study looked at more than 131,000 heart failure hospitalizations in nearly 350 hospitals. The authors found that 11% of patients on loop diuretics were administered at least 500 mL of IV fluids (usually normal saline) in their first two days in the hospital.
Patients receiving those early fluids were found to be more likely than those who did not to be transferred to the ICU (5.7% vs. 3.8%) or intubated (1.4% vs. 1.0%), or to undergo renal replacement therapy (0.6% vs. 0.3%) or die in the hospital (3.3% vs. 1.8%). While those associations can’t be considered causal, says Dr. Bikdeli, they are concerning.
Another finding: The proportion of heart failure patients receiving fluid treatment on top of loop diuretics varied widely among hospitals “from 0% to 71%. The median per-hospital patient percentage was 12.5%.
To get as accurate a snapshot as possible of what the authors believe is inadvertent (and conflicting) dual therapies, researchers excluded patients who likely had a good reason for receiving IV fluids during their first two days in the hospital.
That included patients undergoing invasive cardiovascular procedures. Also excluded were patients with a secondary discharge diagnosis of sepsis, bleeding or anaphylaxis, to minimize the chance of including hemodynamically unstable patients; those receiving vasopressor or inotrope therapy; those being treated for stage 5 chronic kidney disease or end-stage renal disease; and those with an ICU admission or intubation or renal replacement therapy during their first two days of hospitalization.
As Dr. Bikdeli points out, he and his colleagues focused on only those first two hospital days to reduce the odds of picking up on doctors responding to over-diuresis.
“With heart failure patients, clinicians commonly maintain a yin-yang between diuretics and fluids over the course of a hospitalization, bouncing back and forth as diuresed patients get too ‘dry,’ ” he says. “We wanted to look at simultaneous therapy, not sequential treatments being given in response to one another.”
Differences in hospital culture?
As for what the authors called “the remarkable variation among hospitals” in terms of the proportion of patients receiving combined therapies, Dr. Bikdeli admits that he and the investigating team were surprised.
“All of our analysis remained fundamentally unchanged after we standardized patient risk across different hospitals,” he explains. Such variation speaks to either different order sets being used with different EMRs or to other differences in hospital culture.
“Some hospitals may be doing a better job triaging patients,” he notes, “as well as communicating and handing patients off.”
What should hospitals do to find out if their own clinicians are administering dual therapy inadvertently? Do what Yale-New Haven Hospital is now doing, says Dr. Bikdeli: Design a patient-level study to generate your own data.
“Perhaps this dual prescribing is unintentional, or perhaps patients receiving fluids may be sicker with, say, an acute infection, so the fluids contain antibiotics,” he says. “With patient-level data, we should be able to tease out which proportion of such potential scenarios is real.”
Patient-level data may also point to the need for hospital pharmacists to come up with possible fixes. “It would make sense to develop strategies to minimize the use of IV fluids for heart failure patients who need antibiotics or other medications,” Dr. Bikdeli says. He also believes physicians handing off stable patients between services should at least check to make sure that IV fluids aren’t on board.
And while the growing presence of EMRs may be the root of the problem, Dr. Bikdeli says that EMRs can also be a big part of the solution.
Pop-up alerts, for instance, “are being used commonly for other conditions or medications,” he notes. “We can use those for IV fluids being ordered electronically for patients admitted with potential decompensated heart failure.”
Physicians would always be able to override such a warning, adds Dr. Bikdeli, when they have a legitimate reason for ordering fluids.
“An alert is a very low-hanging fruit that almost all hospitals with an EMR can easily implement,” he points out. “It would at least add another layer of support.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.