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Diuresis: a more aggressive approach

A new protocol helps heart failure patients lose more weight safely

June 2013

Published in the June 2013 issue of Today’s Hospitalist

FOR JEFFREY H. BARSUK, MD, the way most physicians order diuretics for hospitalized patients with acute decompensated heart failure calls to mind the tag line for an old infomercial: “Set it and forget it.” But Dr. Barsuk, a hospitalist and associate professor of medicine at Chicago’s Northwestern University Feinberg School of Medicine, finds that approach disconcerting because patients can respond so differently to diuretic doses.

“We were seeing too many physicians starting the drugs and administering them twice a day in an inadequate dose,” he explains.

“Then the next day, they’d circle back to see what happened. Given our understanding of the pharmacokinetics of the drug and how it acts on the kidney, we knew that wasn’t the best way.”

Moreover, says Dr. Barsuk, his hospital’s readmission rates for heart failure patients were higher than the average for UHC, a national alliance of academic centers and affiliated hospitals.

Dr. Barsuk and hospitalists, cardiologists, pharmacists and nurse colleagues from Northwestern formed a multidisciplinary team to design a protocol to explore ways to more quickly remove volume from patients with acute decompensated heart failure. That effort, which was documented in a study published in the March/April 2013 issue of Congestive Heart Failure, found that a more aggressive approach to diuresis was a way for patients to lose more weight safely.

More weight lost
In comparing patients on the protocol to those receiving usual care, researchers found that protocol use was associated with an additional 2.6 kg of weight lost after controlling for many factors, including age, gender, BMI and Charlson score. The authors also found, as they wrote in the study, that “patients treated with the protocol trended toward 1.6 more days in the hospital compared with usual care,” a difference that was not significant. However, the difference in readmission rates was significant: 21.2% among those treated with the protocol vs. 29.2% for those receiving usual care.

Most importantly, however, researchers detected no differences in either mortality (both in-hospital or 30-days post-discharge) or significant kidney failure. The paper concluded that rapid diuresis “appeared to be safe because it did not increase inpatient mortality or the risk of acute renal failure at discharge.” This was particularly noteworthy, the authors explained, because patients who received more intense diuresis using the protocol had a higher severity of illness than those in the usual-care group.

While the research was observational in nature and a more randomized controlled study is needed to confirm its findings (something the group is working on now), Dr. Barsuk says he is a believer in this more-rapid, individualized way of doing diuresis. “I personally believe in this protocol and use it on my patients,” he notes.

“These results reflect pilot data and we cannot rule out selection bias, given the dissimilar number of those on the protocol vs. those who were not,” he adds, pointing out that 68 patients in the study were covered by the protocol while 528 received usual care. “A bigger, randomized controlled trial may show an LOS benefit as well.” It’s possible that this study didn’t show that benefit, Dr. Barsuk speculates, because the protocol wasn’t always started at the beginning of a patient’s hospitalization.

LOS-readmission tradeoff?
The protocol was used for a mean of 5.45 days of patients’ average 7.87 days of total diuretic use, or 70% of all diuretic days. “If these patients received the protocol during the entire duration of hospitalization, greater volume loss may have been achieved faster with a potential decrease in LOS,” the authors wrote.

“There is always a big question of whether there is a tradeoff between length of stay and readmission,” Dr. Barsuk says. Some think that a longer length of stay gives physicians and nurses more time to not only treat but also educate patients. That in turn may reduce patients’ need to be readmitted shortly after discharge.

For the study, Dr. Barsuk and his colleagues designed a loop diuretic protocol for patients with acute decompensated heart failure admitted to Northwestern Memorial Hospital’s cardiac telemetry unit over the course of a year, starting September 2010. Under the protocol, for which the “physicians, nurses, and patient care technicians underwent intense training,” nurses could quickly titrate furosemide or bumetanide (bolus or continuous infusion) on their own without having to obtain additional physician orders.

“This,” says Dr. Barsuk, “empowered the nurses to take ownership of the management of their patients.” Their job was to get 100 to 250 mL of urine output from patients each hour.

To ensure the safety of a more effective diuresis, the nurses had to check electrolytes twice a day and regularly check blood pressure as well as urine output. The protocol was designed to “give more effective but appropriate doses of diuretics” than usual by basing the doses on the amount of volume removed. Each patient received different doses, depending on how much urine he or she excreted per hour.

Attending physician hospitalists could choose to use the protocol or not. The usual approach is to prescribe a fixed daily dose of a diuretic and then check 24-hour urine output and weight loss.

More vigilance, better communication
Another unique aspect of the protocol was that it encouraged patients to get more involved in documenting their urine output and their weight. Dr. Barsuk thinks that the combination of empowering nurses to independently titrate doses and engaging patients may have been the key to the protocol’s success. Those factors may also at least partially explain why patients’ readmission rate was lower for this group.

Individualizing therapy “drove culture change among physicians, nurses, and patients,” the researchers concluded, which in turn led to more patient education and engagement in their own health care, more bedside nursing, and “improved teamwork and collaboration between nurses and physicians.”

As Dr. Barsuk explains, “It probably increased the vigilance of the nurses; they were going into the rooms more frequently.”

The protocol also helped improve communication, he notes, “because I am required to discuss the patient’s progress with the nurse at a minimum of twice a day because we must talk about the second set of labs before any new doses are given.”

Although he didn’t survey the nurses or patients, Dr. Barsuk says the readmission rate of patients treated with the protocol may have dropped not only because they were discharged after being dried out better, but also because patients went home more educated on the importance of “following their weight” and other aspects of self-care.

And looking back, Dr. Barsuk wishes he “had surveyed the nurses to ask them how it burdened them. It did require more intense nursing “but this is a heart failure unit, so this is what we should be doing.”

Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.