Optimizing Volume in Ambulatory Heart Failure Patients: Beyond Oral Diuretics

Abstract

Background

Heart failure (HF) is a chronic, progressive disease that effects over 6 million Americans. Despite growing options in the Guideline Directed Medical Therapy and innovative technology, 25% may return to the hospital within 30 days for IV diuresis. This results in CMS financial penalties for the hospital and personal cost to the patient in reduced quality of life and mortality.

Aim

The purpose of this study is to examine effectiveness of appropriate options for patients that may be resistant to standard oral diuretic volume management utilizing a nurse-run outpatient diuresis center and/or home diuresis with subcutaneous furosemide (Furoscix(R)).

Methods

HF specialists and HF physician assistants (PAs) identify inpatient or outpatient HF clinic patients as volume overloaded and at high risk for readmission. Referral to the nurse-supervised Outpatient Diuresis Clinic by an order set is placed in the Electronic Medical Record for serial weekly infusions (Bumetanide 2 mg or Furosemide 80 mg IVP) with standard lab work (BMP, Magnesium level). After insurance authorization is determined, the appointment is scheduled. A hospital van service provides transportation within a 6-mile radius. When the patient arrives, they are provided a comfortable recliner in a private curtained area. Weight and vital signs are recorded, an IV access placed, and the IV diuretic given. HF provider or CHFN is notified by the infusion nurse if a patient is hypotensive, hypertensive or has a serious lab results requiring Emergency Department evaluation. Labs are reviewed after 2 hours. Oral potassium and magnesium are provided if needed per order set and IV access removed. If distance to the Outpatient Diuresis Center is prohibitive or the patient has difficulty ambulating, Furoscix(R) 80 mg subcutaneous is an effective option. Coverage by insurance is investigated, and the medication ordered through Furoscixdirect.com. Our patients and carepartners are instructed in application in clinic or a trained homecare nurse is ordered for application, clinical assessment and HF education in the home. The collaboration of the CHFN, the HF PAs and MDs with the Diuresis Center and homecare nurses is key to the success of this model.

Results

Between Jan 2022 and November 2024, 74 men and 55 women with HF (N=129), age 30-91, with insurance (Medicare N=100, Medicaid N=24, Commercial N=5) were identified and agreed to Outpatient Diuresis. Thirty-six-point four percent (36.4% N=47) did not go to any Outpatient Diuresis sessions. Of these 47 patients, 36% (N=16) were readmitted in less than 30 days (Average 10.4 days). Adherent patients (63.6%. N=82) attended at least 1 to 4 weekly sessions. Only 6% (N=5) of these patients were readmitted within 30 days (Average 17.2 days). Average hospitalization-free time of the 82 adherent patients utilizing outpatient diuresis and/or Furoscix(R) was 8.76 months, and Furoscix(R) alone, 6.6 months (N=5).

Conclusions

The nurse-supervised Outpatient Diuresis Center is a cost-effective approach to ease the financial healthcare burden and emotional and physical stress of hospitalization. Interdisciplinary HF teams should employ shared decision making in choosing location of volume optimization. More research is needed to identify patient specific barriers to care.