Diuretic management protocol to improve quality and safety in managing acute heart failure in an integrated health system: An implementation science approach.

Background: Effective and timely decongestion in acute heart failure (AHF) coupled with careful discharge planning is critical in the successful treatment of patients hospitalized for AHF. We leveraged an implementation science framework to develop a health system-wide diuretic management protocol (DMP) based on emerging clinical evidence.

Methods: We conducted stakeholder interviews using the Integrated Promoting Action on Research Implementation in Health Services (iPARiHS) Framework. The DMP was vetted through three rounds of recorded virtual interviews with the departments of nursing, pharmacy, hospital medicine and internal medicine residency. Interview content was scored according to a fidelity of implementation system as a primary outcome of acceptance of the protocol. The average scores among stakeholders across DMP iterations illustrated changes in stakeholder perception as the DMP evolved.

Results: Three rounds of interviews were conducted with the stakeholders. From the first to third round interviews, the primary outcome of median averaged scores across clinician and nursing tasks within "satisfaction" improved from 2.8 to 4.3. Similarly, the median "consistency" score increased from 4.0 to 4.3 and the median "quality" score increased from 4.3 to 4.7. First round interview comments demonstrated acceptability for clinician tasks but raised consistent concerns around nursing tasks of reliable assessments of diuretic responses. Protocol modifications streamlined tasks and procedures, and subsequent interviews demonstrated improvement across all metrics.

Conclusions: Our experience of an iterative approach under an implementation science framework demonstrates the development of an increasingly acceptable DMP that incorporates stakeholders' input and helps identify areas to focus on streamlining tasks.