Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2019 Nov 25;4(6):e237.
doi: 10.1097/pq9.0000000000000237. eCollection 2019 Nov-Dec.

Guidelines for Diuretic Utilization Reduce High Charge Medications

Janet M Simsic  1 , Kevin Dolan  1 , Julie Miller  1 , Andrew R Yates  1 , Richard Fernandez  1 , Christina Phelps  1 , Jill Fitch  1 , Anthony Lee  1 , Eric Lloyd  1 , Jennifer Gauntt  1 , Robert Gajarski  1
Affiliations

Guidelines for Diuretic Utilization Reduce High Charge Medications

Janet M Simsic et al. Pediatr Qual Saf. .

Abstract

Decreasing practice variation and following evidence-based clinical guidelines improve patient outcomes and often reduce cost. Essentially all postsurgical cardiac patients require diuretics. The approach to diuresis in the pediatric cardiothoracic intensive care unit (CTICU) is not standardized. Our objective was to develop and implement guidelines for diuretic utilization in the CTICU to reduce high charge medication utilization while maintaining the delivery of high-quality care.

Methods: Two of the top 10 medications by charge in the CTICU during 2016 were diuretics [fenoldopam and intravenous (IV) chlorothiazide]. Standardized diuretic utilization guidelines were developed to reduce the utilization of fenoldopam and IV chlorothiazide. We implemented guidelines in April 2017. The utilization of fenoldopam and IV chlorothiazide, as well as overall diuretic charges, before and after guideline implementation were compared.

Results: We normalized all comparisons to 100 CTICU patient-days. Fenoldopam starts were reduced from 1.1 in 2016 to 0.03 in 2019 (through February); days of fenoldopam use were reduced from 4 in 2016 to 0.15 days in 2019 (through February); IV chlorothiazide doses decreased from 20 in 2016 to 8 in 2019 (through February). These changes reduced the mean charges for diuretics from $25,762 in 2016 to $8,855 in 2019 (through February). CTICU average daily census did not change significantly during the study period (12.8 in 2016 vs 11.8 in 2018).

Conclusion: Value-added implementation of standardized diuretic utilization guidelines in the CTICU successfully reduced the use of high-charge diuretics without unfavorably impacting the quality of care delivery.

PubMed Disclaimer

Figures

Fig. 1.
Fig. 1.
Top 10 diuretic drug charges in the cardiothoracic intensive care unit in 2016.
Fig. 2.
Fig. 2.
Diuretic utilization guidelines.
Fig. 3.
Fig. 3.
Fenoldopam starts per 100 cardiothoracic intensive care unit patient days.
Fig. 4.
Fig. 4.
Fenoldopam days per 100 cardiothoracic intensive care unit patient days.
Fig. 5.
Fig. 5.
Intravenous chlorothiazide doses per 100 cardiothoracic intensive care unit patient days.
Fig. 6.
Fig. 6.
Charges to patient for diuresis per 100 cardiothoracic intensive care unit patient days.
See this image and copyright information in PMC

References

    1. McCammond AN, Axelrod DM, Bailly DK, et al. Pediatric cardiac intensive care society 2014 consensus statement: pharmacotherapies in cardiac critical care fluid management. Pediatr Crit Care Med. 2016;17(3 Suppl 1):S35–S48. - PubMed
    1. Rhodes LA, Robert SM, Atkinson TP, et al. Hypogammaglobulinemia after cardiopulmonary bypass in infants. J Thorac Cardiovasc Surg. 2014;147:1587–1593.e1. - PMC - PubMed
    1. Hirleman E, Larson DF. Cardiopulmonary bypass and edema: physiology and pathophysiology. Perfusion. 2008;23:311–322. - PubMed
    1. Wolfer RS, Bishop GG, Burdett MG, et al. Extravascular fluid uptake during cardiopulmonary bypass in hypertensive dogs. Ann Thorac Surg. 1994;57:974–980. - PubMed
    1. Wernovsky G, Wypij D, Jonas RA, et al. Postoperative course and hemodynamic profile after the arterial switch operation in neonates and infants. A comparison of low-flow cardiopulmonary bypass and circulatory arrest. Circulation. 1995;92:2226–2235. - PubMed