Domiciliary subcutaneous furosemide in patients with CKD and HF: a quality improvement project

Hospital admissions to treat fluid overload are common in patients with both heart failure and chronic kidney disease (CKD-HF). This is a population with high levels of frailty. Recurrent hospital admissions are costly to both patients and healthcare systems. We designed a proof-of-concept, multidisciplinary quality improvement project to deliver at-home subcutaneous furosemide to treat fluid overload in patients with CKD-HF. This project involved collaboration between a hospital, community remote monitoring hub and hospital-at-home team, including general practitioners, secondary care physicians, nurses and pharmacists. Patients were considered suitable for the intervention if they had CKD-HF, fluid overload and were haemodynamically stable. Following review, suitable patients were treated at-home with 80 mg subcutaneous furosemide over 5 hours, for 5 days. This was administered by the hospital-at-home team in liaison with hospital specialists, with continuous patient monitoring provided by the remote monitoring hub. Renal function and weight were assessed daily. Following treatment, patients were reviewed by the secondary-care team to adjust their maintenance medications. Data collected and analysed included daily weights, renal function and observations, as well as the number of hospitalisations and/or death at 30 days following the intervention. 10 patients successfully completed treatment. All potentially required hospitalisation at baseline and all avoided hospitalisation during the 5-day course of subcutaneous furosemide. One patient was admitted to the hospital following their final hospital review, and two patients were hospitalised for 4 and 14 days respectively, after their final dose of subcutaneous furosemide. Renal function and potassium did not significantly change throughout the treatment. No major safety concerns were identified. Patients welcomed the intervention. This quality improvement project demonstrates that it is logistically feasible, with primary care collaboration, to treat fluid overload in patients with CKD-HF at-home using subcutaneous furosemide.