In 2012, the British Heart Foundation (BHF) announced a pilot study to evaluate giving IV diuretics in the patient's home. It claimed that it would end weeks of hospital in-patient care for people with severe heart failure and could be rolled out across the UK if successful (BHF, 2012). We are now beginning to see this being provided for patients in the community, but it is not without its challenges.
For more than a decade, the Department of Health and Social Care has championed a policy of moving services from the hospital environment into the community setting, closer to where patients live (Barton, 2018). In 2017, the National Institute for Cardiovascular Outcomes Research (NICOR) called for improved and earlier detection and management of oedema in the community, to prevent the need for hospital admission (NICOR, 2017). Providing IV diuretics in the home environment meets both of these objectives, but there are far more benefits to this than mere compliance with these two polices.
Heart failure and diuretics
Chronic heart failure (CHF) is a condition associated with ageing (Waterhouse, 2014). Heart failure affects approximately, 1-2% of the adult population, raising to 70% of the adult population over 70 years of age (Passmore, 2016). It has a complex array of symptoms, including breathlessness, fatigue and oedema (Passmore, 2016).
Diuretics are often the first-line treatment for patients with symptomatic heart failure, with the main benefit being symptomatic relief and improvement in quality of life (Passmore, 2016). Removing the excess fluid a patient carries will not just ease oedema, but will also improve breathing and energy levels. Diuretics should be started orally, with IV doses used to manage excessive oedema (National Institute for Health and Care Excellence (NICE), (2021).
Although effective, diuretics do have side effects, including: worsening renal function; hyponatraemia (low sodium levels) and other electrolyte imbalances; gout from raised uric acid levels; and hypotension and dehydration (Passmore, 2016). The risk and severity of these side effects can increase when higher dose diuretics are used.
Patients who have had a sudden weight gain from oedema, who need a faster response or who are experiencing reduced effectiveness of oral treatments will require IV diuretic treatment (Quinn and Read, 2014). This is the moment when a patient will need to be admitted to hospital, and 90% of heart failure patients admitted to hospital will require IV diuretic therapy (Quinn and Read, 2014). IV diuretics are usually continuously administered in hospital every 24 hours, until adequate decongestion is achieved; this is measured by a negative fluid balance, weight loss and symptom relief (Sankaranarayanan et al, 2019). Unfortunately, these patients have a high readmission rate of 20-25% within a month and 40% within 6 months (Sankaranarayanan et al, 2019).
In its study, Brightpurpose (2014) outlined a model for home delivery of IV diuretics. The patient would already be diagnosed with heart failure, receiving IV diuretics via a peripheral cannula in the home or other community setting (hospice day centre or community hospital day centre). Austin et al (2013), Quinn and Read (2014) and Veilleux et al (2014) all described a similar model, excepting the fact that IV diuretic treatment would only be delivered in the home environment. This will be the model discussed. Box 1 contains an outline of each of these studies.
Box 1.Study outlinesBrightpurpose (2014)The British Heart Foundation funded a pilot that enabled 10 NHS trusts to implement and evaluate home-based IV diuretics delivery over a period of 2 years. During its study, 96 patients received a total of 126 IV diuretic treatments. The researchers found:
- Some 79% of patients avoided hospital admission
- Some 63% achieved target reduction in oedema and weight loss
- Approximately 869 hospital bed days were saved
- Some 100% of patients and 93% of carers expressed a preference for community-based treatment
- Some 100% of patients and 96% of carers said they would choose IV diuretic treatment at home.
Austin et al (2013)This study evaluated one community service delivering home IV diuretic treatment. The authors collected data on patient demographics, pre- and post-intervention changes, the wellbeing of the patients and their carers. The study ran for 18 months and evaluated the treatment of 25 patients. The researchers found:
- No adverse reactions from patients receiving treatment
- All patients demonstrated a significant reduction in calf measures, showing a significant reduction in leg swelling
- All baseline observations showed significant improvement after treatment
- Patient satisfaction with the services was rated 90–100%.
Quinn and Read (2014)This is a case study of one patient: a 74-year-old man with ischaemic heart failure. After an assessment at home, he had gained 3 kg in weight in 2 days and had pitting oedema on both lower legs. He was treated with IV diuretics for 16 days (with a break over the weekend when the service was not available, during which he took his oral diuretics). The researchers found:
- During treatment, patient's confusion eased and he became more alert
- He lost 2kg in weight; oedema eased until only affecting his right foot; his bibasal lung crackles eased; his clinical observations and renal function remained stable during treatment
- There were no complications during his treatment
- Patient and his wife were very positive about their experience of the treatment, and stated that they preferred to be treated at home.
Veilleux et al (2014)This was a study by a US hospital to evaluate how effective home IV diuretic treatment is. The authors recruited 60 patients, all with heart failure, who received home IV diuretic treatment during a 2-year period. The researchers found:
- No adverse reactions were observed.
- The readmission rate was 10% of patients, where the local rate amongst heart failure patients was 25%.
- Clinician and patient satisfaction rates were 97% or higher.
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The benefits of intravenous diuretics at home
The BHF funded a pilot project that evaluated 10 different NHS organisations' delivery of IV diuretics in the community (Brightpurpose, 2014). The study lasted 2 years and found the following:
- Some 96 patients received a total of 126 IV diuretic treatments (average length of treatment was 7 days)
- Patients received one or two daily bolus doses
- Some 79% of patients avoided hospital admission
- Some 63% achieved target reduction in oedema and weight loss
- There were approximately 869 hospital bed days saved
- Some 100% of patients and 93% of carers expressed a preference for community-based treatment
- Some 100% of patients and 96% of carers said they would choose IV diuretic treatment at home (Brightpurpose, 2014).
Quinn and Read (2014) and Veilleux et al (2014) reported no adverse reactions from patients during diuretic delivery in the home environment. This is often a concern for clinical staff before a home IV service is commenced, so it is important to note that IV therapy at home can be as safe as that administered in hospital.
Austin et al (2013) and Brightpurpose (2014) reported high rates of patient satisfaction with this treatment, ranging between 90-100%. Veilleux et al (2014) noted that patients were uniformly happy with the service and the fact that they did not have to be admitted to hospital, and that nurses responded quickly to patient concerns. Patients seemed to appreciate avoiding the upheaval, logistical challenges and discomfort associated with being admitted to hospital. Again, this demonstrates patients' preference for staying at home and receiving treatment there, or as near to as possible.
In their case study, Quinn and Read (2014) reported that their patient received 16 days of treatment (minus weekends, when the service was not available). However, this seems to be an exception. Brightpurpose (2014) found that the average treatment lasted only a week, and Austin et al (2013) reported that 86% of treatments lasted 7 days or fewer. These patients did not require constant attendance from a nurse; therefore, several patients could be seen by the same nurse(s) in a day, receiving full monitoring and re-assessment from the nurse during each visit, not just administration of IV diuretics.
Hospital readmission rates were significant factors in the aforementioned studies. Waterhouse (2014) found that home IV diuretic patients spent significantly fewer days in hospital. In their study, Veilleux et al (2014) found a reduction in readmission rates from 25% to 10%; Brightpurpose (2014) reported 869 hospital bed days saved. Even preceding the COVID-19 pandemic, the NHS's lack of resources means that these type of reductions would be welcome. The daily cost of an inpatient bed is £215 to £310 (University Hospitals Birmingham, 2019), and there were a total of 141 000 NHS hospital beds in England in 2018/9 (King's Fund, 2021); the average single A&E treatment costs £400 per patient (King's Fund, 2019). If some of these costs could be reduced on a national level, the savings for the NHS as a whole would be immense.
The challenge of administering diuretics at home
No new services come without challenges, and this is true in this case. These barriers are certainly not insurmountable, but do need careful consideration.
Quinn and Read (2014) identified the need for clinical assessment before starting IV diuretic treatment at home. They assessed a patient for their need for IV diuretic treatment, but consideration should also be taken as to whether a patient is safely able to receive home treatment. There are several factors to take into account when making this kind of assessment. For example, IV diuretic treatment is an acute treatment, and all patients involved in the studies reviewed here had IV access via a peripheral cannula. With the urgency that treatment requires, it is understandable that a long line, such as a peripherally inserted central catheter line or Hickman line, was not used, because safe insertion of these would have delayed treatment. However, peripheral cannulas do not come without complications, especially in older populations; this is a concern, as chronic heart failure is a condition associated with ageing (Waterhouse 2014).
Dougherty (2013) also notes that skin integrity is important for successful venous access. The following factors associated with ageing skin could adversely affect venous access:
- Ageing skin becomes less thick, less elastic and more fragile
- Ageing skin can be damaged or bruised from previous venepuncture sites
- Ageing affects the vein's structural integrity and walls
- Ageing sclerotic veins can ‘roll’, making venous access more difficult
- Ageing veins may seem more prominent, but can be more fragile and easily damaged during venous access
- Older people are much more likely to have been cannulated before and may have had bad experiences
- An older patient may experience confusion or have a condition, such as dementia or Alzheimer's disease, that may impact upontheir understanding of treatment (Dougherty, 2013).
Staff training is essential, as the role of home diuretic delivery is more than just mere administration. Quinn and Read (2014) recruited community heart failure nurses to administer IV diuretics. It was found that these professionals lacked recent cannulation and IV medication administration experience and therefore needed training; however, accessing suitable training proved difficult (Quinn and Read, 2014). Payne (2019) argued that IV administration of any medication in the home is a specialist skill and, therefore, requires dedicated training that is differentiated from that which hospital ward-based nurses receive.
Quinn and Read (2014) also highlighted the role community heart failure nurses have in monitoring and assessing patients during treatment. They undertook clinical observations and monitored the patient's weight, waist circumference, symptoms, fluid balance and renal function. This was important for assessing diuretic dosage, frequency and treatment duration. The development of this critical skillset would also require specialist training if an at-home diuretic delivery model were to be implemented nationwide. Quinn and Read (2014) recruited community heart failure nurses who were familiar with and experienced in undertaking clinical observations; if other kinds of nurses were recruited, they would require dedicated training.
Quinn and Read (2014) left a fluid balance chart with their patient, to be accurately completed. In their study, this task was carried out by the patient's partner. All of the patients included in Austin et al's (2013) study lived with the support of carers. Nowhere is it discussed how to manage a patient who cannot fill out a fluid balance chart, if the patient lives alone, is only visited by carers once or twice a day or the patient is one who experiences confusion.
IV diuretics are often administered on a sliding dosage scale, increasing until the patient responds. Quinn and Read (2014) used a schedule that featured an initial dose of 80mg of furosemide, which would increase or decrease in accordance with the patient's response. The researchers do not state how this schedule was prescribed, although they recruited community heart failure nurses, and it can be assumed there was a significant number of nurse prescribers among them. However, it is reasonable to expect that most services delivering IV diuretics at home will not have ready access to nurse prescribers; therefore, there would need to be a robust system in place to prescribe the diuretics and manage their dosage. The obvious answer to this conundrum would be patient group directives, although these would need to be in place before the diuretic delivery service commenced. Many of the pilots in Brightpurpose (2014) reported this as an issue. Quinn and Read (2014) reported that the patient in their study required a higher dose of diuretics than their schedule allowed, although the researchers did not say how this affected the delivery of the patient's diuretics.
Several of these services did not provide a 7-day-a-week service. Quinn and Read (2014) only provided a Monday-Friday service, with the patients returning to oral diuretics during the weekend. Many of the pilots in Brightpurpose (2014) also only provided Monday–Friday services. Where services were operating on a 7-day basis, Brightpurpose (2014) reported that weekend cover was brought in from other community services. Neither Quinn and Read (2014) nor Brightpurpose (2014) reported any problems with 5-day services, but this does raise questions about actions a patient could take if they experienced any issues over a weekend. Neither Quinn and Read (2014) nor Brightpurpose (2014) report whether these breaks from IV treatment extended the length of treatment the patients required.
Both Austin et al (2013) and Quinn and Read (2014) reported problems with recruiting sufficient nurses to staff their service. Quinn and Read (2014) experienced particular difficulties, as they required two nurses in attendance during each visit to check the dose of IV diuretics. The UK is still facing a national shortage of 38 952 registered nurses—some 11% of the workforce (Ford, 2021)—and these kinds of services require skilled and experienced nurses to deliver the high level of clinical care and safety required during each visit.
Brightpurpose (2014) found that it takes 6 months to establish an operational at-home diuretics administration service, at an average start-up cost of £15660. Quinn and Read (2014) found clinical commissioning groups will fund services that are already proven to be cost-effective and reduce hospital admissions. The author found that there is not a lot of published evidence to back up how effective home diuretic delivery is.
Is this a role for community nurses?
More community nurses are administering IV medications in patients' homes on a regular basis, but their task does not simply end with the administration. With IV diuretics, patients require daily clinical assessment and reassessment to manage their dosage and treatment. Patients may also require twice-daily doses of diuretics, which would necessitate multiple daily visits from a community nurse.
It is not that community nurses lack the skills to perform all the clinical tasks required. Rather, it is a question of whether they have the time and capacity. A visit to administer IV diuretics could easily take an hour or longer. All the studies discussed in this article (Austin et al, 2013; Quinn and Read, 2014; Brightpurpose, 2014) had home IV diuretic treatment established as an independent service, thereby allowing nurses to concentrate on its delivery and enabling the service managers to concentrate on their nurses developing and demonstrating the required clinical skills.
Therefore, this should not perhaps be a role taken on by community nurses, who are already busy enough, but, rather, needs to be a dedicated role in itself.
Conclusion
Providing IV diuretic treatment at home is a relatively new offering that not come without its challenges. The barriers could appear to outweigh any benefits, but the latter, although perhaps not as numerous as we would like, are the most important consideration here. Reducing patient hospital admissions can only be a good thing. It benefits patients, helping them to stay at home, avoid the stress and discomfort of an admission and improve their quality of life. It also saves NHS resources, which, at present, are limited.
Setting up a new service is never straightforward; however, the more it happens, the more likely that better solutions can be found and shared. It can certainly be argued that it worth overcoming the challenges of a service that could have such a positive impact on patients' quality of life.