Implementation of Tailored Intravenous Heart Failure Therapy in a Non-Dedicated Outpatient Infusion Center

Abstract

Symptoms related to volume overload are the most common cause for hospitalization in patients with chronic heart failure. Intravenous loop diuretic therapy is guideline-recommended therapy for reduction of congestive signs and symptoms in the inpatient setting, but the clinical utility of intravenous diuretics post-hospital discharge has not been well characterized. We developed a program for the concurrent delivery of intravenous loop diuretic therapy and self-care education for heart failure patients, who are at high risk for re-hospitalization, within an existing non-specialized outpatient infusion center facility at an academic urban medical center. A dedicated heart failure nurse practitioner worked with full-time infusion center staff nurses to institute a protocol for furosemide administration (bolus dose and 4-hour infusion based on patient weight, volume status, and renal function administered by nursing staff) coupled with a self-care behavior educational program administered by the heart failure nurse practitioner during infusion sessions. The frequency of sessions was individually tailored to patient needs. Since January 2011, we have treated 23 individuals(mean age 70 years) at a total of 252 visits (9 patients required between 1-5 visits, 5 patients between 5-10 visits, 4 patients between 10-20 visits, and 5 between 20-30 visits). Left ventricular ejection fraction (EF) of patients was evenly split with patients’ EF <40% n=12, EF>40% n =11. For each session, median bolus dose of furosemide was 80 mg and median infusion dose was 40 mg/hr with mean urine output 1.4 liters and mean weight loss 1 kg. Infusions were well tolerated with minimal change in blood pressure (mean decrease 3 mmHg systolic blood pressure), and rare transient hypokalemia without clinical arrhythmia. Of 14 patients with re-admission, 3 admissions were elective and 6 had Stage D heart failure and multiple comorbidities. 3 patients have been free of re-hospitalization for >180 days. These preliminary findings demonstrate that heart failure specific therapy can be effectively and safely implemented within existing infusion facilities that are primarily dedicated to other disease states (cancer and rheumatological diseases). This model is a cost efficient strategy that may increase outpatient treatment options where a dedicated heart failure infusion clinic is not feasible.