Implementation of an emergency department electronic interruptive alert to guide intravenous diuretic dosing in acute decompensated heart failure.

BACKGROUND

Intravenous (IV) loop diuretics are the cornerstone of therapy for acute decompensated heart failure (ADHF), yet appropriate initial dosing in the emergency department (ED), particularly for patients receiving chronic outpatient diuretics, remains challenging. To support guideline-recommended dosing, an electronic clinical decision support (CDS) alert was implemented to prompt clinicians to administer at least twice a patient's home diuretic dose intravenously.

OBJECTIVES

To assess clinician acceptance of an ED-based CDS alert recommending guideline-concordant IV diuretic dosing and to identify predictors of alert acceptance.

METHODS

We conducted a retrospective study of ED encounters between May 6 and December 6, 2024, in which the CDS alert fired for patients with ADHF. The primary outcome was clinician acceptance of the alert-recommended diuretic action. Univariable logistic regression with Firth estimation was used to evaluate predictors of alert acceptance.

RESULTS

Among 223 eligible ED encounters, clinicians accepted the alert recommendation in 164 cases (73.5%). Median time from ED arrival to IV diuretic administration was similar between encounters with and without alert acceptance (2.16 [1.34-3.53] vs 2.35 [1.42-3.98] hours). Patients whose clinicians accepted the alert had higher home furosemide-equivalent doses and greater renal dysfunction, including higher serum creatinine (1.47 vs 1.31 mg/dL) and blood urea nitrogen (33.5 vs 28 mg/dL). Predictors of alert acceptance included higher home diuretic dose (OR 1.01), elevated serum creatinine (OR 1.6), elevated blood urea nitrogen (OR 1.02), and White race (OR 0.28).

CONCLUSIONS

An ED-integrated diuretic CDS alert demonstrated high clinician uptake, with acceptance in nearly three-quarters of encounters. Acceptance was more likely among patients with greater illness severity, particularly renal dysfunction. These findings support the potential of CDS tools to optimize diuretic dosing for ADHF in the ED and warrant further evaluation of their impact on clinical outcomes.