Abstract 20397: Linking Improved Processes of Care With Timeliness of Intravenous Diuresis for Acute Heart Failure

Background: Intravenous administration of loop diuretics is a cornerstone of therapy for acute heart failure. We developed the MSH La6 Protocol, a tool to standardize practices for administration, monitoring and dose adjustment of IV furosemide over a 48-hour period. The tool also delegated autonomy to the nurse at the point of care to conduct all actions associated with the La6 Protocol, with the intent of minimizing delays arising from frequent consultation with ordering physicians. The safety and impact of this initiative on markers of quality heart failure care and timeliness of furosemide administration were evaluated. Methods: A pre- and post-implementation time series study analysis was performed. The primary process measure was adherence to daily monitoring of patients receiving IV loop diuretics and was evaluated using composite opportunity and all-or-none scores as well as Shewhart control charts. Outcome measures consisted of the doses of furosemide administered in the first 48 hours of admission to hospital, separated into two 24-hour blocks. Incidence of hypokalemia and increase in serum creatinine as evidence of AKI were evaluated as markers of safety. Results: Between the pre (32 months, n=338) and post (8 months, n=121) implementation period, a significant and stable improvement was observed in the opportunity-based composite score from a mean of 82% to 90% and the all-or-none score from 30% to 57% using Shewhart control charts. Within the pre-implementation cohort, the mean furosemide dose significantly decreased between the 0-24 and 24-48h time block, while no such change was observed within the post-implementation cohort. A significantly larger proportion of patients treated using the La6 Protocol had a dose increase in the 24-48 hour block versus patients treated with usual care. There were no serious adverse events and no deaths. There was no increase in the incidence of hypokalemia or evidence of AKI in the post-implementation cohort. Conclusions: An intervention that resulted in improved adherence to practices for monitoring was also associated with the observation that furosemide dosage was up titrated more frequently early during hospital admission.