Safety and Efficacy of an Automated Nurse-Driven Diuretic Titration Protocol: the Yale Diuretic Pathway

Introduction Congestion is the primary driver of acute decompensated heart failure (ADHF). Unfortunately, diuretic resistance and/or under dosing of diuretics is common, contributing to the large proportion of patients discharged with residual congestion. Given that natriuresis from a dose of IV loop diuretic is nearly complete by 6 h, diuretic titration should occur more frequently than once daily. As such, we designed an automated diuretic titration protocol that would allow nurses to titrate loop diuretic every 6 h. Hypothesis A nurse-driven diuretic titration protocol will provide rapid, effective, and safe titration of loop diuretics. Methods The Yale Diuretic Pathway (YDP) begins with providers ordering the YDP through an EMR order set and specifying (or accepting default) safety parameters such as change in blood pressure (default 0.5 mg/dL increase) and the starting diuretic dose (default 2 mg bumetanide). At 9 AM, the first dose of diuretic is administered, and 2 hours later a spot urine sample is collected, which is used to predict sodium excretion. Based on the YDP algorithm, every 6 h bumetanide is either doubled, administered at the same dose, or held to achieve the daily goal sodium output. The initial EMR order will provide the next AM\u0027s diuretic dose (based on the algorithm) thus giving the provider until 3pm to re-order the YDP if they want automated diuresis to continue. For our analysis, we compared data from 3 days before and 3 days after the start of the YDP. Results 161 hospitalized patients with ADHF received the YDP (age 69±12 years, eGFR 50±2 mL/min/1.73m2). Median time from admission to start of the YDP was 2 (1-4) days, and median dose of IV furosemide equivalents before YDP was 120 (80-140) mg. With the first YDP dose, suboptimal sodium output was displayed with a median calculated 6-hour sodium output of 37 (16-84) mmol. With subsequent doses, mean daily urine output (1817±90 mL pre-YDP vs. 3034±82 mL on-YDP), net fluid output (-1083±86 mL pre-YDP vs. -2071±89 mL on-YDP), and delta weight (pre-YDP -.31±.26 kg vs. -2.54±.34 kg on-YDP) improved substantially (p 0.5 mg/dL. Conclusion The YDP appears to allow fast, safe, and effective titration of loop with significantly improved decongestion following initiation. Further research to formally assess the YDP in randomized setting, and impact of this strategy on clinical outcomes, is warranted.