Clinicians Develop New Diuretic Protocol for Patients Living with Advanced Heart Failure

A group of clinicians led the development of a novel diuretic protocol that will allow allied-health professionals to administer treatment orally or intravenously to homebound patients suffering from advanced heart failure.

 “Treatment (diuresis) for fluid overload common in congestive heart failure is often given orally but may need to be administered intravenously when patient’s symptoms are severe or difficult to treat,” says Dr. Leah Steinberg, an Assistant Professor at the Department of Family and Community Medicine (DFCM) and a physician among the Heartfull Collaborative Team at Mount Sinai.

“We developed a protocol to support clinicians in the use of diuretics for homebound patients living with advanced heart failure.”

In congestive heart failure, a condition where the heart muscle stops functioning properly, patients retain excess fluids causing shortness of breath and swelling in their legs and abdomen. Medication to help the kidneys excrete this fluid is a mainstay of the management of congestive heart failure. Family physicians and palliative care physicians are not always trained in the home-based delivery of intravenous diuretics for patients living with heart failure because it is usually provided in a hospital setting.

The HeartFull team developed a stepwise diuretic protocol and guideline for the assessment, management and monitoring of patients whose goals are aligned with comfort-oriented care. The protocol is initiated when patients experience a worsening of heart failure symptoms.

With members of the Anna Prosserman Heart Function Clinic and The Temmy Latner Centre for Palliative Care, Dr. Steinberg has been working on developing a collaborative care program for patients with advanced heart failure. The collaboration allows palliative care and primary care clinicians to collaborate with cardiology to manage patients with end-stage heart failure at home.  

Roughly 50 percent of patients living with heart failure will die within five years of diagnosis. Patients make frequent hospital visits for symptom management.  Dr. Steinberg and the HeartFull Collaborative believe that homebound patients should be able to receive treatment should their goals be consistent with receiving palliative care at home.

She and the HeartFull Collaborative team have also published a clinical review that describes several elements of palliative care management of patients with end-stage heart failure. The elements include: setting up a collaborative team for patients, monitoring to detect exacerbations early, assessing and managing symptoms, continuing heart failure medications and having a plan to manage exacerbations.

“All five elements are important and while they are not new, using them in a collaborative fashion may improve our ability to keep patients at home. I hope we can continue to expose new DFCM residents to these ways to manage care among advanced heart failure patients.”

The diuresis protocol was created by Dr. Susannah Mak and Dr. Jennifer Arvinitis, a faculty member at DFCM.

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