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CHICAGO -- Ensuring adequate diuretic dosing for patients presenting to the emergency department with acute decompensated heart failure may shorten length of stay, a single-center study showed.

Adequate dosing was associated with a significantly shorter length of stay (P=0.044), according to Jacqueline Fearon-Clarke, MA, of the Gagnon Cardiovascular Institute at Overlook Medical Center in Summit, N.J.

In an analysis of predicted average length of stay, patients who received adequate doses of diuretics had an average stay of 4.2 days, and those who received inadequate doses had an average stay of 5.2 days. However, the difference did not reach statistical significance (P=0.12), Fearon-Clarke reported at the American Association of Heart Failure Nurses meeting here.

She noted that only 26.4% of the patients included in the study received adequate diuretic doses, so "there are definitely potential opportunities for outcome improvement in the development of diuretic dosing guidelines."

Acute decompensated heart failure is one of the leading reasons for presentation to the emergency department and the leading cause of hospitalization at Fearon-Clarke's center. At Overlook, the average length of stay for these patients was 4.72 days and the 30-day readmission rate was 23.6%.

The American College of Cardiology and American Heart Association recommend early and effective diuresis because it has been associated with improved outcomes in this patient population, but dosing of diuretics is variable and is not guided by randomized data.

To look at the relationship between the adequacy of diuretic dosing and outcomes, Fearon-Clarke performed a retrospective chart review of 250 consecutive patients who presented to the emergency department at Overlook with acute decompensated heart failure from October 2008 to July 2010.

The initial IV diuretic dose administered in the emergency department was considered adequate if it was 1.5 times the outpatient oral loop diuretic dose given as an IV bolus or was IV furosemide 80 mg or the equivalent for diuretic-naive patients.

Adequate dosing and male sex were associated with significantly shorter lengths of stay, and systolic blood pressure less than 110 mm Hg, higher serum creatinine levels, and higher body weight at admission were associated with longer lengths of stay (P<0.05 for all).

Both low blood pressure and high serum creatinine levels were associated with the underdosing of diuretics because, Fearon-Clarke said, the clinicians were afraid of making the patients with these characteristics worse.

"The clinicians aren't realizing that a blood pressure of 90 mm Hg is actually normal for these patients on really good heart failure meds," she said.

The predicted 30-day readmission rate also tended to be numerically lower among the patients who received adequate diuretic doses (8% versus 15%), although the difference fell short of statistical significance (P=0.064).

Even so, Fearon-Clarke said, "the implication is that if everyone were getting adequate diuretics presented in the emergency room, that number potentially could be 8% or less and obviously nowhere near the national averages in the 20s."

Armed with these results, Fearon-Clarke and her colleagues developed a heart failure risk assessment tool that incorporates presentation characteristics, laboratory values, physical exam findings, and radiological findings. Patients are classified as having low, medium, or high risk, and given diuretic doses accordingly.

From the American Heart Association:

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