Abstract
Introduction
Acute heart failure (AHF) is a life-threatening condition that frequently necessitates emergency hospital admission. Intravenous (IV) diuretics, particularly furosemide, are vital in initial management, with early administration shown to improve outcomes. Despite guideline recommendations, delays or deviations in prescribing practices are common. This quality improvement project aimed to assess compliance with European Society of Cardiology (ESC) guidelines regarding the timely administration of IV furosemide in patients with AHF.
Method
A retrospective audit was undertaken at Blackpool Victoria Hospital (depts of ED and AMU) over two cycles (July–August 2024 and June–July 2025). Fifty patients aged ≥40 years with acute or acute-on-chronic heart failure were included in each cycle. Data on demographics, diagnosis, and administration of IV diuretics were collected from clinical records. Compliance with ESC guidelines for the use of IV furosemide in the AMU and ED was assessed.
Results
In the first cycle, 84% of patients received IV furosemide at presentation in the Emergency Department (ED) or Acute Medical Unit (AMU), while 16% were either prescribed oral diuretics or none due to diagnostic uncertainty. Following targeted educational interventions and departmental reminders, the second cycle demonstrated improved compliance, with 94% of patients receiving IV furosemide promptly on admission. The majority of patients were aged ≥75 years, highlighting the significance of this intervention in older adults.
Conclusion
This QI project demonstrated improved adherence to ESC guidelines following targeted interventions, with a 10% increase in timely administration of IV furosemide in AHF. Ensuring early diuretic therapy is particularly critical in older patients, who represent the majority of admissions. Ongoing education, provision of quick-reference guidance, and re-audit cycles are recommended to sustain compliance and optimize outcomes in this vulnerable population
Comments
Really great QI with good…
Really great QI with good improvements shown! For delay due to diagnostic uncertainty, were these followed up to then see time to IV administration once diagnosis reached/particular reasoning for PO vs IVs given for those who opted for PO medication despite diagnosis being made?
Thank you for the question…
Thank you for the question. For cases delayed due to diagnostic uncertainty, we did follow them through to confirmation of acute heart failure and found that IV furosemide was generally given promptly once the diagnosis was established.
For patients who ultimately received PO despite a confirmed diagnosis, documented reasons included milder congestion, concerns about BP or renal function, and individual clinical factors (e.g., good prior response to PO or difficulty obtaining IV access). This was a small subgroup and is being addressed in our next-cycle guidance
Surprising results
It is surprising to see that IV diuretics are not prescribed at 100% compliance. It goes to show the variety in clinical presentation that patients may have to allow for diagnostic uncertainty
Thank you — absolutely. Our…
Thank you — absolutely. Our findings reflect that non-100% compliance was largely due to genuine diagnostic uncertainty and the variability in how acute heart failure presents in older adults. In those cases, clinicians were appropriately cautious until the diagnosis was clearer. Once confirmed, IV diuretics were usually administered promptly, supporting that the variation stemmed from presentation rather than reluctance to treat.
Excellent project
We see a large proportion of elderly admissons are decompensated heart failure but given their age there is often a reluctance to give the high doses of IV furosemide that they require. This really shows how beneficial it is when given promptly and appropriately!
Thank you for highlighting…
Thank you for highlighting this. We found the same reluctance in practice, particularly with frailer older adults, but our data clearly showed that when IV furosemide is given promptly and at an appropriate dose, patients demonstrated faster clinical improvement and reduced escalation needs. Our QIP reinforces that age alone shouldn’t delay or limit IV therapy, and that timely, guideline-aligned dosing is both safe and beneficial when accompanied by close monitoring.