Outcomes after implementing a heart failure diuretic pathway in an emergency department setting

Published:October 27, 2022DOI:


      • When patients are diagnosed with decompensated heart failure and signs or symptoms of hypervolemia, they require an intravenous bolus of a loop diuretic that should be equal to the total daily dose prescribed for home use and if not on a loop diuretic, 40 mg dose of furosemide or the equivalent dose of another loop diuretic agent.
      • In this study, emergency department providers under-dosed the initial loop diuretic administered, which could have increased the need for acute hospitalization.
      • Emergency department provider teams and leaders should develop algorithms and quality improvement metrics to enhance adherence to national guideline diuretic recommendations.



      Among patients with acute decompensated heart failure (HF), national and international loop diuretic therapy recommendations may not be followed in the emergency department (ED).


      To examine if loop diuretic treatment and patient disposition from the ED differed after implementing a clinical pathway based on national HF guidelines.


      Using an observational, pre- and post-intervention design, after clinical pathway implementation, loop diuretic medications and clinical outcomes were retrieved from medical records. Analyses included Pearson's Chi-square or Fisher's exact test, 2-sample T-test or Wilcoxon rank sum test.


      Of 182 pre- and 122 post-intervention patients, mean (SD) patient age was 67.9 (13.4) years and 44.2% were Caucasian. There were no between-group differences in pre-ED visit loop diuretic prescription or dosages. More post-intervention ED patients received at least one dose of loop diuretic (94.3% vs. 81.9%, p = 0.010); however, the overall dose (mg) across groups was lower than the home dose and was not based on national guideline expectations. Doses from home to ED decreased less in the post-intervention group for patients who received doses at both time points and for all patients: p = 0.047 and p = 0.048, respectively. There was no between-group differences in short-stay unit (SSU) admissions, p = 0.33. Post-intervention patients were hospitalized from the ED (p = 0.050) and SSU (p = 0.005) less often than pre-intervention patients. Discharge to home from the ED or SSU increased in the post-intervention period; 16.4% vs. 4.9%, p = 0.009.


      Among ED patients treated for HF, diuretic dosing was non-optimized. New interventions are needed to enhance adherence to national guidelines.



      ACCF (American College of Cardiology Foundation), ACEi (angiotensin converting enzyme inhibitor), AHA (American Heart Association), ARB (angiotensin receptor blocker), ARNI (angiotensin receptor neprilysin inhibitor), ED (emergency department), eMR (electronic medical record), HF (heart failure), HFpEF (heart failure with preserved ejection fraction), HFrEF (heart failure with reduced ejection fraction), HFSA (Heart Failure Society of America), SD (standard deviation), US (United States)
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