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Abstract
Background In chronic heart failure many patients have recurrent hospital admissions and it is the leading cause of admission in people aged over 65 years. In those with end-stage heart failure, there is limited evidence that furosemide can be given subcutaneously to relieve symptoms and avoid hospital admission.
Method We initiated a community-based continuous subcutaneous infusion (CSCI) furosemide service for the treatment of advanced heart failure. We aimed to increase patient choice, offer an alternative to hospital admission and, in patients at the end of their life, allow them to die at their preferred place of care with symptom alleviation. We retrospectively reviewed case notes.
Results 36 consecutive episodes of CSCI of treatment were recorded in 28 patients. 15 patients (54%) survived beyond the initial treatment course with 13 patients (87%) avoiding acute hospital admission. There was a reduction in mean hospital admission rates from 2.87 to 0.73 (p<0.001) in the 6-month periods either side of the first episode of CSCI furosemide. A median reduction of 4 kg weight loss was recorded. 13 patients died during the initial treatment course. 12 (92%) died at home and 1 died at the hospital palliative care unit. All had symptoms controlled.
Conclusion Subcutaneous furosemide can be successfully delivered in the community. In addition to palliation in the final days of life, community subcutaneous furosemide can be an effective treatment leading to weight loss and improved symptoms with survival for several months.
- drug administration
- heart failure
- home care
- terminal care
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
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Introduction
Heart failure currently affects approximately 900 000 people in the UK and is the the most common cause of hospital admission in people aged over 65 years.1 Admissions are expected to rise over the next 20 years as the population ages and survival from heart disease improves. Many patients with heart failure, particularly those who have advanced heart failure and may have recurrent admissions, would rather remain at home, but are limited by fluid overload symptoms resistant to oral treatment. Hospital admission can be distressing to those who are approaching the end stage of their life.
Some UK centres offer intravenous or subcutaneous diuretic treatment in the community2 but there are limited data to support this. The largest cohort reported to date is Scarborough, UK where 32 patients with advanced heart failure were treated by a palliative-cardiology multidisciplinary team (MDT) with continuous subcutaneous infusion (CSCI) of furosemide.3 Ninety-three per cent avoided readmission to the hospital and all patients had symptom alleviation in the dying phase. Delivery of subcutaneous furosemide has the advantage that it does not require intravenous access which can be challenging to facilitate in the community and is delivered as a continuous infusion over 24 hours which does not need continuous supervision. Existing palliative care and community nursing teams commonly have experience with this technique which is used to deliver other palliative care medicines.4
Methods
A community-based subcutaneous furosemide service for the treatment of decompensation of advanced heart failure at the Northumbria Healthcare National Health Service Foundation Trust was established. Eligibility criteria included patients who were (1) anticipated to be in the final 12 months of life; (2) on the general practitioner (GP) palliative care register; (3) at a maximal oral diuretic dose and (4) where the patient preference is to be at home or to decline hospital admission. Eligible patients were identified by an MDT of cardiologists, specialist nurses, palliative care and community nursing teams. All patients had an emergency healthcare plan involving the MDT and delivery of the service was facilitated by community heart failure specialist nurses (CHFSN) and district nurses (DN) in the patients’ home supported by secondary care cardiology and palliative care. The daily dose of CSCI furosemide was calculated empirically as 1:1 mg conversion from the patient’s oral furosemide dose or 40:1 mg conversion from oral bumetanide. Treatment was delivered in line with the trust guideline (online supplementary appendix 1). The service was undertaken through a service evaluation governance framework.
Supplemental material
Background and episode-related clinical data was retrospectively collected for all patients. These data included the reason for initiation of therapy, doses and duration of therapy, outcome, weight loss and adverse events. Admission rates for individual patients were compared for the 6-month time period before and after the treatment episode using a paired t-test.
The primary aims of the service were to (1) facilitate heart failure management for patients approaching the end of life at the patient’s preferred place of care and (2) reduce acute hospital admissions. A secondary aim was measured weight loss during treatment.
Results
A total of 28 patients (79% males) received CSCI furosemide. Eight additional episodes of CSCI furosemide occurred in seven patients following a successful initial treatment episode. The median age (IQR) was 78 years (74–83). The majority (16/28, 57%) had severe left ventricular systolic dysfunction (LVSD), defined as ejection fraction below 35%. Other aetiologies included mild or moderate LVSD (5/28) and right heart dysfunction (7/28). Figure 1 describes the treatment episode outcomes.
Description of the place where a CSCI furosemide treatment episode was completed for (A) those who survived and (B) those who died (place of death). CSCI, continuous subcutaneous infusion; PCU, palliative care unit.
The median (IQR) length of treatment was 11 (8–20) days. The median (IQR) starting dose of furosemide was 200 mg (200–120) with a range of 120–300 mg.
Sixteen of 28 patients commenced treatment with a goal of receiving care at home and to reduce hospital admissions. Twelve patients had treatment for symptom management at the end of life, 11 of which died during the episode.
Fifteen of 28 patients survived beyond the initial subcutaneous furosemide treatment with a median (IQR) survival time of 6 (3–10) months. There was a reduction in the admission rate from 2.87 admissions to 0.73 (95% CI: 1.35–2.91; p<0.001) in the 6-month periods either side of the first episode of CSCI furosemide. In the 15 patients who survived, a median reduction of 4 kg was recorded.
Thirteen of 28 patients died during their first episode of CSCI furosemide treatment (an additional 5 patients who had survived an initial treatment episode with CSCI died during a subsequent episode). Fourteen of 18 patients who died were commenced on CSCI furosemide as part of the end of life care. Four of 18 patients were receiving more active treatment for decompensation and subsequently deteriorated rapidly. All four chose to stay at home for the end of life care.
Sixteen of 28 treatments were initiated in the hospital during admission for decompensation of heart failure; 12 of 28 were initiated in the community. All of the eight repeat treatment episodes were initiated in the community.
Twenty-five of 28 patients (89%) completed their initial treatment course in the community, whereas 3 (11%) required completion in an inpatient palliative care unit. Of those three requiring inpatient palliative care support, two were direct transfers from inpatient wards and one unplanned via the emergency department due to inability to tolerate CSCI in the community. Two (7%) episodes of community treatments resulted in an unplanned acute admission. These were due to abnormal blood tests in one and the inability to tolerate CSCI in the other.
In terms of complications, one patient (3%) developed an infusion site reaction requiring oral antibiotic treatment. In 6 of 28 patients, there were some challenges in managing the syringe driver (where it was reported as cumbersome or limited mobility, needle site pain or alert alarms of the syringe driver resulted in DN night time calls).
The patients had been under the care of local heart failure services and specialist nurses for a median (IQR) time of 12 (4–16) months before commencing the intervention with no aetiology group having a longer preintervention diagnosis time.
Discussion
CSCI furosemide can offer end-stage heart failure patients’ management in the community and may provide an alternative treatment to conventional intravenous therapy, which typically needs to be given in a hospital setting. In our cohort, CSCI furosemide was well tolerated by our patient group, which is in keeping with the previously reported literature.3 5 For those patients who survived a treatment episode, CSCI furosemide was associated with a reduction in further admissions in this high-risk group. We observed that a course of treatment was also associated with weight loss and symptom improvement. This service increased patient choice in a setting of limited options and terminal decline. In those imminently dying, CSCI furosemide allowed palliation and death in the environment of their choice without compromising on efforts towards symptom management.
The service improved the working relationship between our heart failure and palliative care teams in the hospital and the community. This enhanced our overall advance care planning and end of life discussions with patients. The development of this relationship was a crucial link to the success of the service. It is likely that there will be additional benefits to other aspects of patient care as a result of this more careful and integrated approach.
Delivering this new treatment brings some challenges. Our service relied on DN and community cardiology nurses for delivery with no additional funding available. CSCI furosemide increased demand on an already stretched community team by caring for patients who would have otherwise been in hospital, many of whom were at the end of their life. This required engagement and education of our DN team supported by CHFSN and local GPs. We believe this service has reduced heart failure admissions to an inpatient heart failure service that is hugely stretched. We estimate that it has also saved the healthcare economy money. The average heart failure admission in the UK lasts 9 days6 with a cost of £1795–£4008 dependent on comorbidities.7
CSCI furosemide at home is not for everyone. Some patients prefer to be in a hospital or have insufficient support at home to facilitate treatment. Some patients’ expectations of what treatment at home entails cannot be met. Delivering furosemide continuously via a syringe driver can be cumbersome. However, this may still be preferred over hospital admission and the discomfort and risks this poses.
The weight loss data that we have are limited and potentially vulnerable to reporting bias in that only patients who improved and survived were weighed. However, it does offer evidence that the CSCI furosemide is effective as a diuretic and is able to reduce heart failure-related oedema.
Since this work has been carried out we have expanded this service in order to offer it to a larger number of patients with end-stage heart failure. The effectiveness of the CSCI treatmentalso prompted us to develop our service offering this treatment to a group of patients with less advanced illness as an alternative to hospital admission. Some centres offer ambulatory care or community intravenous diuretics for this group. However, we feel the subcutaneous approach has significant advantages with respect to access and personnel to administer the medication. This has been useful and practical in our response to the COVID-19 pandemic where patients are increasingly concerned about the increased risk associated with hospital admissions and attendance. There remain limited data in this area and this work offers evidence that our strategy is safe, well tolerated and effective.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
Ethics statements
Patient consent for publication
Footnotes
Contributors HT designed data collection tools, revised the paper, monitored and led the project. She is the guarantor. AB designed data collection tools, analysed the data, drafted and revised the paper. KW analysed the data, drafted and revised the paper. JR and LA designed and implemented the project, designed data collection tools, revised the draft paper. IM, CR and DR designed and implemented the project and revised the draft paper.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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