Heart Failure Patients on Intravenous/Subcutaneous ( IV/SC ) Diuretics - Clinical Guidelines for the Discharge from Hospital of

Publication: 12/07/2017  --
Last review: 01/01/1900  
Next review: 01/07/2020  
Clinical Guideline
CURRENT 
ID: 5107 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2017  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Clinical Guidelines for the Discharge from Hospital of Heart Failure Patients on Intravenous/Subcutaneous (IV/SC) Diuretics

These guidelines must be used in conjunction with the Leeds Community Healthcare NHS Trust Clinical Guideline for ‘Providing Intravenous/Subcutaneous (IV/SC) Diuretics in the Community Setting for Patients with Heart Failure

Identification of the patient
Inclusion Criteria
Exclusion criteria
Relative Exclusion Criteria (Physician Review)
Procedure to Follow
Appendix 1 - Checklist for discharging patients from LTHT on IV Furosemide
Appendix 2 - Treatment Plan for Community Parenteral Furosemide Therapy Community Intravenous Additives Service (CIVAS)
Appendix 3 - IV Diuretic Leaflet for Patients

1. Identification of patient (This should only be decided by the Heart Failure (HF) Specialist team)

Patients who are able to be discharged safely who only need on-going hospital stay for the administration of intravenous (IV) diuretics to aid treatment of their heart failure may be eligible for discharge with home administration of IV Furosemide.  This will be supervised by the Heart Failure Specialist Nurses in the Community with support from Dr Alex Simms, Consultant Cardiologist and team via telephone or virtual clinic follow-up/referral. The patient will be discussed in the regular Heart Failure Multi-Disciplinary Team meetings.

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1.1 Inclusion Criteria

  • Age 18 or above
  • Registered with a Leeds GP
  • Confirmed  left ventricular systolic dysfunction (LVSD)
  • Require at least 48 hours or more of IV (or subcutaneous - SC) Diuretics at time of Consultant or Heart Failure Team in-reach review in Hospital.
  • If not for IV diuretics in hospital would otherwise be fit for discharge home
  • Whilst in hospital, demonstrated at least 1kg weight loss the preceding 24 hours and no significant on-going symptoms
  • Deemed to have stable renal function and that other blood parameters if deranged are improving
  • Must have a Heart Failure plan of care regarding escalation and appropriateness of further therapies
  • No significant concerns about achieving IV access
  • Consent to the treatment (or done in their best interests in line with the Mental Capacity Act (MCA) 2005)
  • Fully functioning phone to receive and make calls at all times and that the patient can use it.
  • The patient must have adequate social arrangements to manage IV / SC therapy

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1.2 Exclusion Criteria

  • Under 18 years old (or up to age of 19 years receiving a service from the Children’s Services)
  • Patients who do not give consent who have capacity to do so
  • Patients suffering from haemophilia or other bleeding disorder
  • An alternative treatment, via any other route, which could be prescribed as a suitable alternative is available
  • They do not have a venous access device that is appropriate in relation to the type of drug to be administered and the length of the treatment plan
  • There are any environmental issues which make treatment in the community setting unsafe or impractical
  • They do not have a fully functioning accessible phone that is capable of making and receiving calls at all times
  • A risk assessment should be carried out for patients who have a history of substance misuse to determine suitability for IV therapy. This should consider their current history/reason IV therapy is required.
  • They are cognitively impaired / confused and do not have access to a formal/informal carer
  • They are homeless

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1.3 Relative Exclusion Criteria (Physician review)

  • Patients who have symptomatic postural hypotension
  • If patients Creatinine >300µmol/l, Sodium <125mmol/l, Potassium <3.5mmol/l

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2. Procedure to follow

  • The Heart Failure specialist team will check that the patient is otherwise medically and socially fit for discharge. They will assess the patient and decide whether discharging them on IV furosemide is an option.
    Assessment should be against the above guidelines. This must be discussed with the patients’ consultant and team and the discussion documented in the notes.
  • The medical team that the patient is under should confirm that the patient can be discharged and document this in the notes
  • The service is then explained to the patient and verbal consent gained and documented in the notes. The patient is made aware that will only be possible if the community team have capacity to take them on.
  • The patient is given an information leaflet
  • If the patient requires subcutaneous diuretics then please discuss with the community Heart Failure Specialist Nurse or the Palliative Care team.
  • If the patient requires IV furosemide then check that the Heart Failure Nurse (HFN) in community can see the patient within the appropriate time frame. This should be a HFN that can prescribe and alter dose as necessary. Agree the date that the patient will be seen by the community HFN to be reassessed and how many days of IV furosemide will be supplied by the trust. Document this on the treatment plan.
  • Discuss the plan to be followed if the cannula comes out and cannot be replaced. Document this on the treatment plan
  • Contact the community intravenous additives service (CIVAS) team to check capacity and discuss the plan
  • Aim for the patient to be discharged mid-afternoon after both doses of IV furosemide are given if they are on BD doses. If the patient is on a 24 hour infusion where possible aim for discharge between 17.00 - 18.00 hours - this may depend on patient circumstances.
  • The CIVAS team should go in to the patient the next morning to give the first community daily dose of IV furosemide and daily in the morning thereafter until the patient is reviewed by the community HF specialist nurse. Ensure they plan to give the IV furosemide in the mornings.
  • The IV furosemide should be continued until review by the community HFN who will decide whether to stop the treatment or continue and prescribe further treatment.
  • LTHT HF team should discuss the discharge with the ward team and document in the notes. Document  a contact number for the LTHT HF team and CIVAS - ask the ward to contact them if  there are problems with discharge (or for anything else they may want to discuss)
  • Discuss with the ward pharmacist and technician and guide them with what to put on the edan and what to supply ( furosemide vial only). Ensure it is clear on the Edan that the furosemide is not for repeat prescription but that enough is prescribed until the HF community nurse sees the patient.
  • Return to patient to discuss the plan, check the patients discharge arrangements, inform the patient of who to contact and when, CIVAS team, HF special out of hours if CIVAS not available
  • Teach the patient what to do (for example to stop any bleeding) if their cannula comes out
  • Ensure cannula VIP score is zero before discharge - if not remove cannula - the community team will insert a new one if necessary
  • LTHT HF team (non- medical or medical prescriber) completes the treatment plan with instructions on how to give the diuretics, when to do the bloods etc (attached)
  • Copy of the treatment plan into the notes
  • Copy of the treatment plan to the CIVAS team via email
  • Copy of the treatment plan to the HFN in community with the proforma that is currently sent.
  • Complete the checklist and put it into the notes
  • Patient sent home with treatment plan, edan , cannula documentation and IV’s. HFN (LTHT) checks edan just before discharge and also checks with the ward that the patient has gone home.
  • HFN LTHT records the discharge on IV Diuretics on the data tool noting how many bed days are saved (i.e. how many days the patient remains on IV diuretics & therefore would have been in hospital had the service not been available). This may need to be sourced from the community HF team once the IVs have finished.

NB For actions in the community please see Intravenous Diuretic Service (IVD) Guide (attached). The IVD guide has been written by the community cardiac team for patients that are already in the community and will be put on IV diuretics. Some of the actions will overlap with the actions taken by the LTHT staff.

Provenance

Record: 5107
Objective:
Clinical condition:
Target patient group:
Target professional group(s): Pharmacists
Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

Not supplied

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Appendix 1 - Checklist for discharging patients from LTHT on IV Furosemide
Appendix 2 - Treatment Plan for Community Parenteral Furosemide Therapy Community Intravenous Additives Service (CIVAS)
Appendix 3 - IV Diuretic Leaflet for Patients

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Equity and Diversity

The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group.