The Role of Outpatient Intravenous Diuretic Therapy in a Transitional Care Program for Patients With Heart Failure: A Case Series

Abstract

We present a case series of seven patients with an established diagnosis of heart failure enrolled in a transitional care program that were treated with intravenous diuretic therapy in the outpatient setting. The patients presented in this cases series were treated due to the development of decompensated heart failure within 30 days of their discharge from our hospital. All seven patients stated that they would have originally presented to the emergency department for their symptoms, but consented to alternative treatment by a transitional care physician, or transitionalist. These patients with decompensated heart failure (four male and three female) with a median age of 55 years (24 - 84 years) were evaluated and treated from November 2011 to March 2012. Of the seven patients, four presented with decompensated systolic heart failure (three with diastolic). All seven patients were treated with an intravenous diuretic for hypervolemia in our outpatient infusion room. All of the patients experienced relief of their dyspnea the day of diuretic administration or the following day. No adverse effects or emergency department transfers occurred as a result of outpatient intravenous diuretic therapy. Through the use of outpatient intravenous diuretic therapy, we have avoided the need for emergency department visits and potential hospitalization in select patients with decompensated heart failure. Based on our preliminary findings, the clinical efficacy of this approach to the treatment of heart failure decompensation is not only due to the pharmacologic effectiveness of intravenous diuretics, but also due to the bidirectional open line of communication that exists between transitionalist and patients in the program. The direct telephone access that patients have to the transitionalist allows for close post-hospitalization monitoring and facilitates timely evaluation and treatment when acute issues arise. The added benefit of our particular transitional care program is that we have an alternate venue in the hospital where our transitional care patients can be treated for heart failure decompensation (our outpatient infusion room), thus, enabling us to avoid emergency department transfers and possible hospital admissions. Further investigation of this therapy in a non-emergency department setting is warranted as our experience with this treatment modality is limited to the case series presented.

Team-Based Care for Outpatients with Heart Failure

“…Ryder and colleagues 126 found that 72% of patients were stabilized and did not require hospitalization, 124 and Banerjee and colleagues 129 noted that 94% of patients were not admitted within 28 days following their outpatient IV diuresis regimen. [126][127][128] Unsurprisingly, considerable cost savings were noted when hospitalization was not required. 126,127,129 Further benefit was seen when outpatients receiving IV diuretics were linked with an HF disease management program.…”

“…[126][127][128] Unsurprisingly, considerable cost savings were noted when hospitalization was not required. 126,127,129 Further benefit was seen when outpatients receiving IV diuretics were linked with an HF disease management program. 124,126,127,129 Patients at high risk for recurrent HF exacerbation were closely monitored and able to receive an immediate response to changes in clinical status.…”

“…Safety of outpatient IV diuresis has been demonstrated, and in some study participants it decreased congestive symptoms, increased fluid weight loss, and improved NYHA class. [125][126][127][128][129] In addition, HF hospitalization was reduced. Ryder and colleagues 126 found that 72% of patients were stabilized and did not require hospitalization, 124 and Banerjee and colleagues 129 noted that 94% of patients were not admitted within 28 days following their outpatient IV diuresis regimen.…”

“…126,127,129 Further benefit was seen when outpatients receiving IV diuretics were linked with an HF disease management program. 124,126,127,129 Patients at high risk for recurrent HF exacerbation were closely monitored and able to receive an immediate response to changes in clinical status. An essential component of IV diuretic programs is frequent patient reassessment by HF specialists within days following outpatient IV diuresis to determine overall response and the need for diuretic adjustment.…”

Decreasing Heart Failure Revisits

“…It is geared toward patients who do not require the length or level of services provided by inpatient care but require management beyond traditional ED care [38]. Descriptive studies demonstrated the efficacy of the observation medicine approach (see supplement) [39][40][41]; however, there are no RCTs that examined 30-day revisit rates. Identification of the right patients, right services, right therapies, right length of treatment and right level of care providers that lead to optimal patient safety and best outcomes are needed.…”