https://orcid.org/0009-0006-7395-0850
Figures
Abstract
Background
Heart failure (HF) significantly impacts healthcare systems due to high rates of hospital bed utilization and readmission rates. Chronic HF often leads to frequent hospitalizations due to recurrent exacerbations and a decline in patient health status. Intravenous (IV) diuretic administration is essential for treating worsening HF. Emerging strategies include home-based IV diuretic therapy administration; however, limited practical implementation guidance is available. This scoping review aims to summarize the literature on home IV diuretic administration for HF patients, focusing on the interventions’ characteristics, and facilitators and barriers to its implementation.
Methods
This review followed the scoping review framework proposed by Arksey and O’Malley and PRIMSA-ScR. A comprehensive search was conducted across six databases (CINAHL, the Cochrane Library, EMBASE, MEDLINE, PsychINFO and Scopus) and grey literature to identify English studies from inception to April 13, 2024. Two independent reviewers screened articles and resources for inclusion and data was extracted using a form created by the authors in Covidence.
Results
The search yielded 2,049 results, with nine studies meeting the inclusion criteria. Studies varied in design, including feasibility, pilot, observational, and pre/post-intervention evaluations. The majority were conducted in European countries, with sample sizes ranging from 12 to 96 patients receiving home IV diuretics for HF. Key implementation challenges include appropriate patient selection, IV cannulation competency of healthcare providers, and multi-disciplinary and multi-agency collaboration.
Conclusions
Evidence on home IV diuretic administration practices for HF management remains limited. However, this scoping review suggests that commonalities across studies could form the basis for developing standard protocols in outpatient settings. Despite the lack of formal evidence-based guidelines, the findings also suggest that tailored, community-specific approaches and safe infusion guidance documents could enhance the efficacy and scalability of home IV diuretic therapy. Future research should focus on refining these strategies and exploring diuretic escalation methods beyond traditional acute care administration to optimize patient outcomes.
Citation: Krauter MB, McGilton KS, Patel SS, Harkness K, Colella TJF (2025) Home intravenous diuretic administration for heart failure management: A scoping review. PLoS ONE 20(1): e0316851. https://doi.org/10.1371/journal.pone.0316851
Editor: Vincenzo Lionetti, Scuola Superiore Sant’Anna, ITALY
Received: October 5, 2024; Accepted: December 17, 2024; Published: January 17, 2025
Copyright: © 2025 Krauter et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its Supporting Information files.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Heart failure (HF) poses a significant global health burden, with high rates of hospital readmission and mortality affecting patients around the world [1]. Despite advances in treatment, many patients experience frequent hospitalizations and declining quality of life, highlighting the urgent need for improved HF management strategies across counties and health systems [1–3]. The course of chronic HF is troubled by recurrent exacerbation episodes and an overall decline in health status, resulting in frequent hospitalizations and poor quality of life [1, 2] Loop diuretics in the form of furosemide are the treatment of choice for symptomatic relief of HF congestion [1, 3]. However, as the disease progresses, patients become less responsive to oral furosemide and require intravenous (IV) administration to address issues of diuretic resistance and cardio-renal dysfunction [4, 5].
International guidelines recommend administering IV furosemide in a hospital setting [1, 6, 7]. However, emerging literature supports alternative outpatient care pathways for HF in efforts to minimize disruption to patients and families and decentralize treatment away from hospital settings [8–11]. For instance, outpatient treatment of patients with worsening HF can avoid delays in diuretic treatment, streamline interdisciplinary HF care, and facilitate early follow-up [12]. Outpatient IV diuretic therapy refers to administration in ambulatory clinics, such as infusion clinics or day units [13]. This may also include administering IV diuretics in the patient’s home. Nevertheless, there is a paucity of evidence regarding outcomes and challenges to home infusion therapy.
The scope of home infusion therapy is growing as healthcare services expand to provide comparable care to patients outside of the hospital setting. The administration of IV anti-infectives, chemotherapy, hydration, pain management, and immunotherapy is widely used in homes for managing chronic conditions such as cancer, gastrointestinal and neuromuscular and immune diseases [14–18]. The emergence of home-administered IV diuretics for HF signifies a major shift in treatment, offering benefits like patient convenience, cost savings, and reduced acute healthcare resources [8–10, 19]. Small-scale observational studies indicate that home IV furosemide can safely and effectively promote weight loss, alleviate congestion symptoms, and decrease emergency department visits and hospital admissions for some HF patients [20–22]. However, determining suitable candidates for outpatient parenteral diuretic treatment remains challenging, as eligibility involves factors beyond disease presentation, including comorbidities, psychosocial conditions and support systems [20].
Despite the growing adoption of home-based IV diuretic therapy, no review has summarized the factors influencing the home administration of IV diuretics in HF management. Furthermore, no practice standards or evidence-based clinical recommendations guide its use or address operationalization challenges. This underscores the importance of understanding this practice’s evolving implications, challenges, and opportunities to inform evidence-based decision-making, optimize patient care, and shape future research and policy initiatives. This scoping review aimed to examine and summarize the available literature on home IV diuretic administration for patients with HF. The specific research questions of this review are:
- What are the key characteristics of the home IV diuretic HF intervention?
- What are the facilitators and barriers to implementing home administration of IV furosemide in HF management?
Methods
Design and rationale
The scoping review methodological framework by Arksey and O’Malley [23] was used to guide this work with enhancements from the works of Levac et al. [24] and Peters et al. [25]. This design was chosen as it allows for an exploratory, inclusive approach to systematically map the breadth of current evidence across various study types and sources [23, 26]. Reporting adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR), and the corresponding PRISMA-ScR Checklist is available in the S1 File [27, 28].
Search strategy. A comprehensive search strategy aimed to identify full-text publications on adult patients (age ≥ 18 years) with HF receiving IV diuretics in their homes. Six health databases, including the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Database of Systematic Reviews, EMBASE, MEDLINE, PsychINFO and Scopus for full articles written in the English language. A search example of Medline is included in the S2 File. All database search results were exported using the reference manager ZoteroTM and imported to CovidenceTM, a web-based collaboration software platform. A manual search for relevant references from abstract-only sources was conducted for completeness. Finally, a search of grey literature was conducted using the same keywords within Google Scholar and combined using search modifiers. No date limit was used to capture the historical use of IV diuretics in home HF management. Database searches were conducted on April 13, 2024.
Eligibility criteria.
The inclusion criteria was established according to the participants, concept and context of the scoping review research question and is as follows [25]:
- Full-text articles available in the English language;
- Adults (age ≥ 18 years);
- Patients with a diagnosis of HF (as defined within each article), regardless of etiology or ejection fraction;
- Patients receiving IV diuretic administration in the home setting (e.g., where the patient lives, such as their apartment, house or a relative’s home). Home is defined as where the patient lives, such as their apartment, house, or a relative’s home (Montana Code Annotated, 2021).
Grey literature that provided information on the process or effect of the intervention was included.
Articles were excluded if they were:
- Abstracts, reviews, protocols, book chapters, editorial letters, dissertations, or websites;
- Administration of IV diuretics to patients living in long-term care homes or equivalent (e.g. skilled nursing facilities) or in outpatient settings, such as infusion clinics or day units;
- Patients receiving mechanical circulatory support were excluded since this select group requires an alternative care model.
Study selection.
Once duplicates were automatically removed by Covidence, study screening was conducted by two independent reviewers (MK and KH). Screening criteria were piloted on 3 articles before being applied to all studies. Eligibility criteria ranking resulted in first exclusion if no full text was available (e.g. abstract only), followed by intervention type (e.g. IV diuretic delivery not in the home setting), and subsequent screening for population (e.g. adults with HF). The selection consisted of an initial title and abstract review, followed by a full-text review for inclusion and exclusion criteria. Conflicts were resolved by a third reviewer (TC) or through discussion with all reviewers until consensus was achieved.
Data extraction.
The research team developed a standardized data collection form through consensus guided by Sidani and Braden’s intervention theory [29] to capture key information relevant to the research questions. This theory was used to detail the essential components of the IV diuretic intervention, resources needed, and the client, contextual factors and resources that influence home IV diuretic administration. Consistent with the iterative nature of scoping reviews, the charting tables were continually updated as the review team became familiar with source results [23]. The following data were collected from each study: author information, publication year, country, study design, study aims, and details about participants and IV diuretic administration events. The extraction tables were piloted on three articles by two independent reviewers (MK and KH) and reviewed by the team before finalizing. Two researchers (MK and SP) independently coded data and completed the Covidence extraction.
Collating, summarizing and reporting the results.
The general characteristics of the included studies were analyzed using descriptive statistics to identify trends or patterns. A descriptive numerical summary is provided on the number of studies included, types of study design, years of publication, characteristics of the study populations, and countries where studies were conducted.
To address the first research question, deductive content analysis used components of the intervention theory, as defined by Sidani and Braden [29], as initial codes to categorize and organize extracted information on home IV diuretics. This textual analysis facilitated the examination and structuring of the narrative data describing home IV diuretics’ characteristics, such as dose, equipment and administration processes. Results from the charting data were collated and further described in the results section.
To address the second research question, articles were read to identify supportive strategies and barriers to home IV diuretic use. Findings from the process were organized according to human, design, and system themes, influenced by the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) taxonomy [30, 31]. The NCC MERP taxonomy was utilized for its comprehensive and structured approach to categorizing factors influencing safe medication administration [31]. A formal methodological quality assessment for the included studies was not undertaken since scoping reviews are intended to provide a broad synopsis of the existing evidence, regardless of the methodological quality [25].
Results
Literature search
A comprehensive search of electronic databases yielded 2,049 results, and an additional two resources were identified through grey literature and reference list searches. Following the removal of duplicates, title and abstract screening, 99 full-text studies were assessed for eligibility. Nine articles published from 2005 to 2023 were included in the final sample. The PRISMA flow diagram (Fig 1) presents a summary of the literature search.
Study characteristics
The included studies’ general characteristics are outlined in Table 1. The included articles ranged from 2005 to 2023, with more than half of the studies (5; 56%) published in 2020 and later. Most studies were conducted in European countries (6; 67%) [32–37], and three (33%) were conducted in North America [38–40]. In terms of the study design, three (33%) were feasibility studies [38–40], three (33%) pilot studies [34, 36, 39], two retrospective single-site observational studies [35, 41], and one (12.5%) pre/post-intervention evaluation [33].
The administration of IV diuretics in the home was the primary study aim in four of the nine studies (44%) [32, 34, 35, 40], whereas the others evaluated home IV diuretics within a program focused on symptom management [35] or home HF visiting programs by nurses or community paramedics [36–39]. Two (25%) studies reported mixed intervention groups (N = 121), including both IV and subcutaneous (SC) diuretic administration [33, 34].
A total of 211 participants were included across the 9 studies, with a range of sample sizes from 12 to 96 (mean 45) [32–40]. The age of patients included in the studies ranged from 37 to 90 years, with a mean age of 75 [34–42]. Patient sex was reported in seven (78%) of the nine studies [32–35, 37–39]. The percentage of female patients ranged from 14% to 50%, with a total of 108 female patients reported across all studies [32–35, 37–39]. One (12.5%) study reported ethnicity, where 24.1% were non-white ethnic minorities [32].
All studies included adult patients with a diagnosis of HF who failed to respond to increasing doses of oral diuretic treatment residing within a pre-specified catchment area [32–40]. Five (56%) studies recruited patients during their hospital admission [32, 37–40]. New York Heart Association (NYHA) and left ventricular ejection fraction (LVEF) criteria varied across studies and are further detailed under ‘Client Factors’. Most articles (n = 6; 67%) excluded patients who demonstrated hemodynamic instability due to hypotension or metabolic and electrolyte abnormalities [32–34, 37–39].
Due to heterogeneity in the reporting of NYHA and LVEF, the authors were unable to present an accurate categorical reflection of the patient population. Overall, five (56%) studies reported NYHA status II-IV indicating treatment of symptomatic HF [33–36, 39]. There was a lack of standardized LVEF reporting structure according to international guideline-recognized phenotypes. In the six (67%) studies that reported LVEF, home IV furosemide was used across all LVEF subtypes and was not a consideration for treatment decisions [32, 34, 35, 37–39]. Patients included across all studies presented with a variety of co-morbid conditions (e.g., ischemic heart disease, hypertension, atrial fibrillation, renal dysfunction, lung disease, diabetes mellitus, anemia, frailty). Reporting of co-morbidities across studies was inconsistent and, therefore, difficult to summarize within the final sample. Additional information regarding co-morbidities of each study are available in Table 2.
The intervention
Sidani and Braden’s [29] intervention theory helps describe the intervention at conceptual and operational levels. Conceptually, it outlines the intervention’s overall goal and active components. Operationally, the theory guides how elements are translated into specific components, detailing the content, activities, mode of delivery, timing, sequence, and dose. These components as described by authors are summarized in Table 3.
Goal of home IV diuretics.
The general goal of home IV diuretic therapy is to achieve symptom relief from fluid congestion and avoid acute care utilization. The articles present that this approach can be further differentiated into remedial approaches that target active management and restoration of euvolemia, versus palliative treatment measures, focusing on comfort and quality of life. Six (67%) studies administered home IV diuretic therapy for acute management of decompensated HF episodes [32, 36–40], while two (22%) studies administered it solely for palliative care purposes [33, 35], and one study combined both indications [34].
Medication mode of delivery.
Furosemide was the diuretic of choice in all studies [32–40]. Administration of the IV furosemide was specified by peripheral IV (PIV) catheter in five studies (55%) [32–34, 38, 39] and by peripherally inserted central venous catheter (PICC) in two studies (22%) [34, 35]. The medication was delivered via continuous infusion in four studies (44%) [32, 35, 38, 40] compared to bolus dosing in two studies (12.5%) [33, 34].
Dose, timing and sequence.
Five articles (56%) reported on daily IV furosemide doses [32–35, 39]. The majority (n = 4, 44%) used doses ranging from 40 mg to 250 mg [32–34, 37, 39], though Godino et al. [35] reported a maximum daily dose of 480 mg (mean 302.5 mg) in the setting of long-term (average 271 days) IV infusion by PICC for end-stage HF management. Otherwise, the length of home IV diuretic treatment ranged from 1 to 17 days, with most studies (56%) reporting a 7-day average length of treatment [32–34, 37, 39]. Intravenous diuretic administration frequency was daily in four studies (45%) [32, 33, 35, 40], up to twice a day in three studies (33%) [34, 37, 39], and up to three times a day in one study (11%) [36]. One study described weekday-only administration [40] and two studies supported 7-days per week service [32, 39].
Medication administration activities.
Diuretic protocols are treatment algorithms for flexible diuretic dose titration based on a patient’s response to diuretics [42, 43]. Automated diuretic dose augmentation can occur when signs and symptoms of worsening congestion are present, such as body weight gain, lack of HF symptom improvement, or worsening peripheral edema [33, 40]. They promote timely dose adjustment without the need for physician reassessment. Examples of diuretic protocols were used in four studies (44%) [33, 34, 38, 40], and one study (12.5%) outlined a decision pathway for treatment at home versus day unit according to renal function [32].
Treatment monitoring parameters were reported in seven studies (78%) [32, 34, 36–38, 40]. Standard parameters included bloodwork for electrolytes and renal function, weight, vital signs, and symptomology (NYHA status) (n = 6, 67%) [32–34, 36, 37, 40]. Others included complete blood count (n = 1, 11%) [33], electrocardiograms (n = 1, 11%) [36], phlebitis scores (n = 1, 11%) [33], and subjective scores for care satisfaction and caregiver burden (n = 2, 22%) [33, 34]. Three studies (33%) described virtual services, including remote home monitoring systems for weight and vital signs and telehealth services to connect in-home providers with HF specialists [32, 38, 40]. One study (11%) described follow-up care, requiring patients to attend an in-person outpatient HF clinic 30 days following therapy initiation [37].
Other administration activities included medication verification and documentation. One study (11%) described medication verification by two nurses before delivery [34], while another (11%) performed verification by mailing a photo to the central office [37]. Documentation of therapy by the health care provider was described in three studies (33%) [32, 36, 38]. Two studies (22%) utilized charts left in the patient’s home [36, 38], and one (11%) used a standardized electronic template uploaded to the electronic medical record [32].
Patient factors
Patient factors are the personal and health or clinical characteristics that may influence the intervention [29]. Patients were excluded from studies based on clinical, psychosocial, or resource-related factors which may have influenced the effectiveness of the IV diuretic program. Clinical factors that resulted in the exclusion of patients from home IV diuretic programs include hemodynamic instability (e.g. systolic blood pressure less than 90 mmHg, tachycardia due to uncontrolled arrhythmia, or hypoxia), metabolic abnormalities (e.g. hyponatremia, hypo- or hyperkalemia, elevated creatinine indicative of acute kidney injury or on dialysis) or who were experiencing worsening HF because of another acute medical illness that required treatment, such as worsening chronic obstructive pulmonary disease, renal failure, or anemia [32, 33, 37–39]. Most articles (n = 6, 67%) excluded patients with hemodynamic instability due to hypotension or metabolic and electrolyte abnormalities [32–34, 37–39]. Patients were excluded in five studies (56%) if they had inadequate social support or were perceived to have unsafe home environments [32–34, 38, 39]. One study (11%) cited limited staff coverage and excluded patients if they required weekend care [37].
Contextual factors.
Contextual factors are defined as the physical, psychosocial, and political features of the setting in which health professionals deliver an intervention and the environment or life circumstances in which clients apply treatment recommendations, impacting the intervention’s optimal implementation and ultimate outcomes [31]. Two (25%) studies reported on patients’ living status, with 73% (N = 70) to 100% (N = 25) of patients living with a caregiver or family [33, 34]. Contextual factors such as home safety with access to electricity, water and heat, and securement of pets were noted in the inclusion criteria of two (22%) studies [33, 39]. Details regarding patients’ living environment, such as whether they lived in a house, apartment, or urban versus rural locations, were unavailable. Factors such as education, employment, income, social support and security, partner status, and diagnosis of depression or anxiety have been shown to impact morbidity, mortality, hospital readmission rates, pharmacotherapy adherence, and the cost of care of patients living with HF [44, 45]. These are known to be interrelated psychosocial factors that significantly impact HF-related outcomes but were not outlined in the included review articles.
Resources.
Resources are the material and human assets necessary for delivering home IV diuretics [29]. Material resources include cannulas and dressings, IV bags and tubing, PICC accessories (e.g., dressings), blood draw equipment, and monitoring equipment like vital sign machines and scales [32–40].
Human resources encompass all personnel involved, such as clinician prescribers and IV furosemide administrators whose qualifications and attributes significantly impact the intervention’s implementation and effectiveness [32, 34, 36–40]. Eight studies (89%) specified physicians as the prescriber for home IV diuretic therapy [32–34, 36–40], with four (44%) describing shared prescribing between HF specialists, emergency department and primary care [32, 38–40], and two (22%) involving a non-physician prescriber, such as an advanced practice nurse (APN) [39, 41].
Home care nurses were the predominant providers for home IV diuretic administration [32–34, 36, 37, 40]. Two studies (22%) described utilizing paramedics [38, 39], and one study (11%) [35] involved a non-healthcare provider, caregiver, or family member administering IV diuretics. Notably absent in the literature was the role of the pharmacist.
Facilitators and barriers.
Facilitators and barriers related to home IV diuretic administration were organized at the human, design, and system levels [31], all of which could influence the effectiveness of the intervention. These are presented in Table 4. Human-level factors were identified based on how authors described the roles, responsibilities, and interactions of healthcare professionals, patients, and caregivers in managing home IV diuretic therapy. Common human-level facilitators include clinical expertise in HF, multidisciplinary engagement, and professional education and training [32, 34, 36–38, 40]. Education for home care providers was described in studies to focus on HF care (n = 7, 78%) [32, 34–38, 40], and IV cannulation and medication administration (n = 5, 56%) [34–38, 40]. Human-level barriers included provider safety concerns about medication side effects in the home setting, inappropriate patient selection, staffing limitations to meet the needs of service delivery, and poor communication between the prescriber and the medication administer which led to care coordination issues [32–34, 36, 38–40].
Design-level factors focused on structural elements that influence the delivery of home IV diuretic therapy, such as organizational strategies, care coordination approaches, and logistical considerations. These included multidisciplinary approaches to care delivery that enhanced partnerships between hospital networks, primary care and homecare services, for example, through documentation, combined visits, and case reviews [32, 34, 36, 38–40]. Supportive design factors enhanced documentation, point-of-care testing, and evaluation, ensuring seamless communication between team members. The authors identified the most significant operational challenge as skill maintenance for IV canulation [34, 35, 37–40]. Additionally, resource constraints were identified when inadequate staffing or medication supply was interrupted [33–36, 38, 40].
System-level factors include broader healthcare dynamics, policies, regulations, and resource allocation. System-level facilitators included effective multi-agency communication, strong project leadership, and sufficient lead-in time to implementation to organize stakeholder’s [32, 34, 38–40]. System barriers to home IV diuretic administration included unclear cost reimbursement strategies and a lack of sustainable program funding [34, 38, 40].
Discussion
Home IV diuretics are used in the management of HF patients despite a lack of formal guidelines or clinical recommendations [20, 46]. This scoping review provides the most recent evidence on home IV diuretic treatment in HF patients, focusing on their key characteristics and the facilitators and barriers to its implementation. Nine studies were identified, offering insights into international home IV diuretic use from 5 countries administered to 211 participants. Commonly, home IV diuretics were used to address congestive symptoms of HF while attempting to avoid hospitalization [32–35, 40]. Studies selected adult patients with symptomatic HF of any type and co-morbid conditions whose hemodynamic and metabolic measures were stable, excluding vulnerable patients who were unlikely to cope with the added burden of parenteral care, such as increased urine output at home and infusion-related equipment [32–34, 38, 39]. Few studies detailed the socioeconomic factors essential to support patients in the home setting, and only two articles considered patient prreference for home IV therapy [32, 38].
Overall, the studies utilized IV furosemide dosing and procedures akin to standard care, often involving the administration of high doses via peripheral IVs or PICC lines in short bolus infusions [1, 6, 7, 47]. This is similar to other observational studies using IV furosemide in the outpatient clinic setting, suggesting that the standard dosing protocols are consistently applied across different clinical environments and patient populations, reeinforcing the reliability and generalizability of IV diuretic dosing [48–52]. The uniformity in dosing practices indicates a recognition and acceptance of the efficacy of these protocols despite the absence of robust randomized data.
The dosing approaches observed in these studies included a total daily dose of 40 to 240mg of furosemide, commonly administered via bolus delivery for 1 to 2 weeks [32–34, 37, 39]. Although specific dosing intervals were not always explicitly outlined, standard care practices would typically suggest twice-daily dosing for total daily amounts at or above 80mg, with higher doses up to 120mg twice a day [53]. Additionally, the study by Godino et al. reported a mean daily dose of 302.5 ± 176 mg; however, this dosing regimen was delivered through a continuous infusion pump rather than bolus injections, reflecting a variation in administration method that may impact overall efficacy and ability to support this intervention.
There are no practice standards or evidence-based clinical guidelines for using home IV diuretic therapy in HF management. This review highlights essential elements needed to develop such standards. The Gorski Model for Safe Home Infusion offers a potential framework that emphasizes five aspects of care: patient selection, comprehensive care planning (including assessment and monitoring), interprofessional communication and collaboration, patient and caregiver education, and home care organization [54–56]. Essential elements identified in this review include 1) Patient selection criteria that identify potential candidates based on both clinical and psychosocial factors; 2) The ability to obtain IV access is an essential skill of nursing and paramedicine; however, it was a rate-limiting factor in supporting home IV diuretic therapy identified by both professions [33, 34, 38]; 3). Multidisciplinary and multiagency collaboration facilitated by regular communication and supportive staffing structures; and, 4) Tailored approaches that are necessary to address specific local needs and challenges, such as detailed roles and responsibilities, established communication channels, and exhaustive implementation planning [57–60]. This review did not find detailed information on patient and caregiver experiences or education, though future research to address this need is critical for active participation, informed decision-making, and potentially mitigating home IV therapy risks and complications in specific patient populations [61, 62].
This review demonstrates the evolution of healthcare team models to meet evolving patient and health system needs. Novel integration of paramedics into the homecare setting poses unique opportunities and challenges. While helpful in addressing health resource issues, integrating paramedics requires careful consideration of training requirements, the scope of practice delineation from nursing, and coordination with existing healthcare teams [38, 39, 63, 64]. Surprisingly absent were primary care providers, and pharmacists, who are known to play pivotal roles in HF management [65–68]. APNs appeared in the literature less than anticipated. APNs are essential in managing heart failure, as they provide critical support in complex treatments, enhance provider-patient communication, and ensure effective symptom monitoring and response. Incorporating APNs into home IV diuretic therapy can address significant implementation barriers and support advanced homecare practices [69–74]. It is prudent for future research design and evaluation to focus on implementation frameworks that enhance the equitable, sustainable and scalable deployment of home IV diuretics across different environments.
Finally, the use of subcutaneous (SC) furosemide is growing in popularity. This evolving delivery strategy has similar bioavailability and efficacy as IV infusion, does not require cannulation, and can allow patients to self-administer and titrate [75–77]. The use of IV and SC diuretics in patients with advanced chronic HF remains an area of high priority for future research to determine its clinical and cost-effectiveness in contrast to combined oral diuretic strategies [78, 79].
Strengths and limitations
The strengths of this review include a rigorous and reproducible search strategy guided by a librarian. The results included all available evidence in full-text on home IV diuretics for patients with HF. The scoping review methodology included grey literature and did not exclude studies based on methodological quality to provide a fulsome summary of home IV diuretic treatment for patients with HF. Although scoping reviews typically focus on information breadth rather than depth, the intervention theory used for data collection and analysis helped to structure the narrative data presented in the wide range of articles, ensuring a complete collection of relevant details and context to shape our interpretation and understanding [27].
The limitations of the review are influenced by the lack of available literature on home IV diuretics. The exclusive search for English-language articles in the search strategy may have exacerbated this. The search revealed several abstracts on home IV diuretic use for patients with HF (n = 41) that may have contributed to a broader understanding of different models of care but were excluded in the absence of full-text publication. Literature suggests that many abstracts fail to be published in total, which can lead to publication bias where positive results are more frequently published than neutral or negative results [80]. For our investigation, this may result in a misunderstanding of real-world challenges for implementing home IV diuretic programs.
The major limitation of this publication is the lack of comprehensive evaluation regarding the outcomes and effectiveness of home IV diuretic therapy for HF. Fully understanding these outcomes is challenging due to variability in study designs, small sample sizes, and diverse patient population. The differences in home care protocols, implementation, and patient monitoring and reporting complicate the standardization of approaches for evaluation or directly compare study results. These limitations underscore the need for more rigorous studies and reporting structures to clarify the true impact of home IV diuretic therapy on long-term HF outcomes.
Conclusion
This scoping review synthesized the literature to determine how home administration of IV diuretics impacts patients and families, healthcare providers, and the healthcare system. Home IV diuretic programs for HF aim to optimize healthcare resource utilization by shifting aspects of HF management from acute care settings to the home environment while maintaining quality of care and patient safety [32–35, 40]. Many barriers to its operationalization were identified, but none appear insurmountable if countered with strategic implementation. This area of practice continues to lack rigour compared to other cardiovascular therapeutics due to the limitations of available randomized controlled evidence [81]. Future research should validate IV home diuretic protocol and establish contemporary clinical guidance documents on developing, implementing, and evaluating this intervention.
Supporting information
S1 File. Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist.
https://doi.org/10.1371/journal.pone.0316851.s001
(DOCX)
S2 File. Sample search strategy in Ovid MEDLINE.
https://doi.org/10.1371/journal.pone.0316851.s002
(DOCX)
References
- 1. Ezekowitz JAO’Meara E, McDonald MA, Abrams H, Chan M, Ducharme A, et al. 2017 Comprehensive Update of the Canadian Cardiovascular Society Guidelines for the Management of Heart Failure. Can J Cardiol. 2017 Nov;33(11):1342–433. pmid:29111106
- 2. Virani SA, Zieroth S, Bray S, Ducharme A, Harkness K, Koshman SL, et al. The Status of Specialized Ambulatory Heart Failure Care in Canada: A Joint Canadian Heart Failure Society and Canadian Cardiovascular Society Heart Failure Guidelines Survey. CJC Open. 2020 May;2(3):151–60. pmid:32462129
- 3. Mullens W, Damman K, Harjola V, Mebazaa A, Brunner‐La Rocca H, Martens P, et al. The use of diuretics in heart failure with congestion—a position statement from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail. 2019 Feb;21(2):137–55. pmid:30600580
- 4. Wilcox CS, Testani JM, Pitt B. Pathophysiology of Diuretic Resistance and Its Implications for the Management of Chronic Heart Failure. Hypertension. 2020 Oct;76(4):1045–54. pmid:32829662
- 5. Gupta R, Testani J, Collins S. Diuretic Resistance in Heart Failure. Curr Heart Fail Rep. 2019 Apr;16(2):57–66.
- 6. Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation [Internet]. 2022 May 3 [cited 2023 Oct 21];145(18). Available from: https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063
- 7. McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599–726.
- 8. Bews HJ, Pilkey JL, Malik AA, Tam JW. Alternatives to Hospitalization: Adding the Patient Voice to Advanced Heart Failure Management. CJC Open. 2023 Jun;5(6):454–62. pmid:37397619
- 9. Hamo C.E., Abdelmoneim S.S., Han S.Y., Chandy E., Muntean C., Khan S.A., et al. Outpatient Intravenous Lasix Trial in Reducing Hospitalization for Acute Decompensated Heart Failure (OUTLAST). Circulation. 2020;142(SUPPL 3).
- 10. Quinn KL, Stukel TA, Campos E, Graham C, Kavalieratos D, Susanna Mak, et al. Regional collaborative home-based palliative care and health care outcomes among adults with heart failure. Can Med Assoc J. 2022 Sep 26;194(37):E1274. pmid:36162834
- 11. Van Spall HGC, Lee SF, Xie F, Oz UE, Perez R, Mitoff PR, et al. Effect of Patient-Centered Transitional Care Services on Clinical Outcomes in Patients Hospitalized for Heart Failure: The PACT-HF Randomized Clinical Trial. JAMA. 2019 Feb 26;321(8):753–61. pmid:30806695
- 12. Lee C, Llewellyn J, Beleznai T, Jackson C, Nyjo S, Hassan S, et al. PO054 Ambulatory Management of Acute Decompensated Heart Failure Is Safe and Efficacious. Glob Heart. 2018 Dec;13(4):398–9.
- 13. Girerd N, Mewton N, Tartiere JM, Guijarro D, Jourdain P, Damy T, et al. Practical outpatient management of worsening chronic heart failure. Eur J Heart Fail. 2022;24(5):750–61. pmid:35417093
- 14. Board N, Brennan N, Caplan GA. A randomised controlled trial of the costs of hospital as compared with hospital in the home for acute medical patients. Aust N Z J Public Health. 2000 Jun;24(3):305–11. pmid:10937409
- 15. Docherty T, Schneider JJ, Cooper J. Clinic- and Hospital-Based Home Care, Outpatient Parenteral Antimicrobial Therapy (OPAT) and the Evolving Clinical Responsibilities of the Pharmacist. Pharmacy. 2020 Dec 7;8(4):233. pmid:33297356
- 16. Haywood HB, Fonarow GC, Khan MS, Van Spall HGC, Morris AA, Nassif ME, et al. Hospital at Home as a Treatment Strategy for Worsening Heart Failure. Circ Heart Fail [Internet]. 2023 Oct [cited 2024 Apr 21];16(10). Available from: https://www.ahajournals.org/doi/10.1161/CIRCHEARTFAILURE.122.010456
- 17. Levine DM, Ouchi K, Blanchfield B, Saenz A, Burke K, Paz M, et al. Hospital-Level Care at Home for Acutely Ill Adults: A Randomized Controlled Trial. Ann Intern Med. 2020 Jan 21;172(2):77. pmid:31842232
- 18. Polinski JM, Kowal MK, Gagnon M, Brennan TA, Shrank WH. Home infusion: Safe, clinically effective, patient preferred, and cost saving. Healthcare. 2017 Mar;5(1–2):68–80. pmid:28668202
- 19. Le N, Rahman T, Kapralik JL, Ibrahim Q, Lear SA, Van Spall HGC. The Hospital at Home Model vs Routine Hospitalization for Acute Heart Failure: A Survey of Patients’ Preferences. CJC Open. 2022 Mar;4(3):263–70. pmid:35386130
- 20. Cuthbert JJ, Clark AL. Diuretic Treatment in Patients with Heart Failure: Current Evidence and Future Directions–Part I: Loop Diuretics. Curr Heart Fail Rep. 2024 Apr;21(2):101–14. pmid:38240883
- 21. Payne D. Intravenous diuretic administration in the home environment. Br J Community Nurs. 2021;26(12):599–603. pmid:34878910
- 22. Ryder M, Murphy NF, McCaffrey D, O’Loughlin C, Ledwidge M, McDonald K. Outpatient intravenous diuretic therapy; potential for marked reduction in hospitalisations for acute decompensated heart failure. Eur J Heart Fail. 2008;10(3):267–72. pmid:18308632
- 23. Arksey HO’Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005 Feb;8(1):19–32.
- 24. Levac D, Colquhoun H, O’Brien KK. Scoping studies: advancing the methodology. Implement Sci. 2010 Dec;5(1):69. pmid:20854677
- 25. Peters MDJ, Marnie C, Tricco AC, Pollock D, Munn Z, Alexander L, et al. Updated methodological guidance for the conduct of scoping reviews. JBI Evid Implement. 2021 Mar;19(1):3–10. pmid:33570328
- 26. Munn Z, Peters MDJ, Stern C, Tufanaru C, McArthur A, Aromataris E. Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Med Res Methodol. 2018 Dec;18(1):143. pmid:30453902
- 27. Tricco AC, Lillie E, Zarin W, O’Brien K, Colquhoun H, Kastner M, et al. A scoping review on the conduct and reporting of scoping reviews. BMC Med Res Methodol. 2016 Dec;16(1):15. pmid:26857112
- 28. Sarkis-Onofre R, Catalá-López F, Aromataris E, Lockwood C. How to properly use the PRISMA Statement. Syst Rev. 2021 Dec;10(1):117, s13643–021-01671-z. pmid:33875004
- 29.
Sidani S, Braden CJ. Nursing and health interventions: design, evaluation and implementation. Second edition. Hoboken, NJ: Wiley-Blackwell; 2021.
- 30. Hartwig SC, Denger SD, Schneider PJ. Severity-indexed, incident report-based medication error-reporting program. Am J Hosp Pharm. 1991;48:2611–6. pmid:1814201
- 31.
National Coordinating Council for Medication Error Reporting and, Prevention (NCC MERP). NCC MERP Taxonomy of Medication Errors [Internet]. Office of the Secretariat, United States Pharmacopeia.; 1998. Available from: https://www.nccmerp.org/sites/default/files/taxonomy2001-07-31.pdf
- 32. Ahmed FZ, Taylor JK, John AV, Khan MA, Zaidi AM, Mamas MA, et al. Ambulatory intravenous furosemide for decompensated heart failure: safe, feasible, and effective. ESC Heart Fail. 2021;8(5):3906–16. pmid:34382749
- 33. Austin J, Hockey D, Williams WR, Hutchison S. Assessing parenteral diuretic treatment of decompensated heart failure in the community. Br J Community Nurs. 2013;18(11):528–4. pmid:24471224
- 34. Brightpurpose. Evaluation of IV diuretics pilot: Final report for British Heart Foundation [Internet]. 2014. Available from: https://www.shfnf.co.uk/wp-content/uploads/2014/10/Final-Evaluation-Report-IV-Diuretics-August-2014.pdf
- 35. Godino C, Scotti A, Marengo A, Battini I, Brambilla P, Stucchi S, et al. Effectiveness and ost-efficacy of iuretics ome dministration via eripherally nserted entral enous atheter in atients with nd- tage eart ailure. Int J Cardiol. 2022 Oct;365:69–77.
- 36. Holdgaard A, Johansen S, Gadsbøll N. Home-based care and treatment of patients with severe heart failure. Sygeplejersken Dan J Nurs. 2005;105(3):28–33.
- 37. Van Ramshorst J, Duffels M, De Boer SPM, Bos-Schaap A, Drexhage O, Walburg S, et al. Connected care for endocarditis and heart failure patients: a hospital-at-home programme. Neth Heart J. 2022 Jun;30(6):319–27.
- 38. Feldman BA, Rivera OE, Greb CJ, Jacoby JL, Nesfeder J, Secheresiu P, et al. “House Calls” by Mobile Integrated Health Paramedics for Patients with Heart Failure: A Feasibility Study. Prehosp Emerg Care. 2022;26(6):747–55. pmid:34505798
- 39. Severson S, Fink A, McCoy R, Liedl C, Bieber P, Juntunen M, et al. Community Paramedic Home Care Program for Acute Decompensated Heart Failure: A Pilot Study. Circ Cardiovasc Qual Outcomes [Internet]. 2023 Sep [cited 2024 Apr 20];16(9). Available from: pmid:37470393
- 40. Veilleux RP, Wight JN, Cannon A, Whalen M, Bachman D. Home diuretic protocol for heart failure: partnering with home health to improve outcomes and reduce readmissions. Perm J. 2014;18(3):44–8. pmid:25102518
- 41. Ahmed H, VanderPluym C. Medical management of pediatric heart failure. Cardiovasc Diagn Ther [Internet]. 2021;11(1). Available from: https://www.scopus.com/inward/record.uri?eid=2-s2.0-85101353137&doi=10.21037%2fCDT-20-358&partnerID=40&md5=be7f85d62f40835ebf6e7c6d520b0538 pmid:33708503
- 42. Piano MR, Prasun MA, Stamos T, Groo V. Flexible Diuretic Titration in Chronic Heart Failure: Where Is the Evidence? J Card Fail. 2011 Nov;17(11):944–54. pmid:22041332
- 43. Steinberg L, White M, Arvanitis J, Husain A, Mak S. Approach to advanced heart failure at the end of life. Can Fam Physician Med Fam Can. 2017;63(9):674–80. pmid:28904030
- 44. Albus C, Waller C, Fritzsche K, Gunold H, Haass M, Hamann B, et al. Significance of psychosocial factors in cardiology: update 2018: Position paper of the German Cardiac Society. Clin Res Cardiol. 2019 Nov;108(11):1175–96. pmid:31076853
- 45. Richardson LG. Psychosocial Issues in Patients With Congestive Heart Failure. Prog Cardiovasc Nurs. 2003 Jan;18(1):19–27. pmid:12624569
- 46. Hughes A, Oluyase AO, Below N, Bajwah S. Advanced heart failure: parenteral diuretics for breathlessness and peripheral oedema–systematic review. BMJ Support Palliat Care. 2024 Mar;14(1):1–13. pmid:36585222
- 47. Jain R, Stone JA, Agarwal G, Andrade JG, Bacon SL, Bajaj HS, et al. Canadian Cardiovascular Harmonized National Guideline Endeavour (C-CHANGE) guideline for the prevention and management of cardiovascular disease in primary care: 2022 update. Can Med Assoc J. 2022 Nov 7;194(43):E1460–80. pmid:36343954
- 48. Buckley LF, Carter DM, Matta L, Cheng JW, Stevens C, Belenkiy RM, et al. Intravenous diuretic therapy for the management of heart failure and volume overload in a multidisciplinary outpatient unit. JACC Heart Fail. 2016;4(1):1–8. pmid:26656139
- 49. Durango LF, Li HK, Katz SD, Wencker D. Outpatient Treatment of Refractory Heart Failure with Intravenous Furosemide Infusion. J Card Fail. 2006 Aug;12(6):S115.
- 50. Halatchev IG, Wu WC, Heidenreich PA, Djukic E, Balasubramanian S, Ohlms KB, et al. Inpatient versus outpatient intravenous diuresis for the acute exacerbation of chronic heart failure. Int J Cardiol Heart Vasc. 2021;36(101649525):100860. pmid:34485679
- 51. Verma V, Zhang M, Bell M, Tarolli K, Donalson E, Vaughn J, et al. Outpatient Intravenous Diuretic Clinic: An Effective Strategy for Management of Volume Overload and Reducing Immediate Hospital Admissions. J Clin Med Res. 2021;13(4):245–51. pmid:34007363
- 52. Wierda E, Dickhoff C, Handoko ML, Oosterom L, Kok WE, De Rover Y, et al. Outpatient treatment of worsening heart failure with intravenous and subcutaneous diuretics: a systematic review of the literature. ESC Heart Fail. 2020 Jun;7(3):892–902. pmid:32159279
- 53. Felker GM, Ellison DH, Mullens W, Cox ZL, Testani JM. Diuretic Therapy for Patients With Heart Failure. J Am Coll Cardiol. 2020 Mar;75(10):1178–95.
- 54. Gorski LA. Infusion therapy: A model for safe practice in the home setting. Am Nurse J. 2020;15(6):8–11.
- 55. Gorski LA. A Look at 2021 Infusion Therapy Standards of Practice. Home Health Care Now. 2021;39(2):62–71.
- 56.
Gorski LA, Alexander M. Fast Facts for Nurses About Home Infusion Therapy [Internet]. 1st ed. New York: Springer Publishing Company; 2017. (The Expert’s Best-Practice Guide in a Nutshell). Available from: https://connect.springerpub.com/content/book/978-0-8261-6006-5
- 57. Alderwick H, Hutchings A, Briggs A, Mays N. The impacts of collaboration between local health care and non-health care organizations and factors shaping how they work: a systematic review of reviews. BMC Public Health. 2021 Apr 19;21(1):753. pmid:33874927
- 58. Busari J, Moll F, Duits A. Understanding the impact of interprofessional collaboration on the quality of care: a case report from a small-scale resource limited health care environment. J Multidiscip Healthc. 2017 Jun;Volume 10:227–34. pmid:28652761
- 59. Green BN, Johnson CD. Interprofessional collaboration in research, education, and clinical practice: working together for a better future. J Chiropr Educ. 2015 Mar 1;29(1):1–10. pmid:25594446
- 60. Schot E, Tummers L, Noordegraaf M. Working on working together. A systematic review on how healthcare professionals contribute to interprofessional collaboration. J Interprof Care. 2020 May 3;34(3):332–42. pmid:31329469
- 61. Fields BE, Whitney RL, Bell JF. Managing Home Infusion Therapy. AJN Am J Nurs. 2020 Dec;120(12):53–9. pmid:33214375
- 62. Reinhard S, Young H, Levine C, Kelly K, Choula R, Accius J. Home Alone Revisited: Family caregivers providing complex care [Internet]. AARP Public Policy Institute; 2019. Available from: https://www.aarp.org/content/dam/aarp/ppi/2019/04/home-alone-revisited-family-caregivers-providing-complex-care.pdf
- 63. Dainty KN, Seaton MB, Drennan IR, Morrison LJ. Home Visit‐Based Community Paramedicine and Its Potential Role in Improving Patient‐Centered Primary Care: A Grounded Theory Study and Framework. Health Serv Res. 2018 Oct;53(5):3455–70. pmid:29542111
- 64. Shannon B, Eaton G, Lanos C, Leyenaar M, Nolan M, Bowles K, et al. The development of community paramedicine; a restricted review. Health Soc Care Community [Internet]. 2022 Nov [cited 2024 Jul 28];30(6). Available from: https://onlinelibrary.wiley.com/doi/ pmid:36065522
- 65. Anderson DA, Clemett V. What impact do specialist and advanced-level nurses have on people living with heart failure compared to physician-led care? A literature review. J Res Nurs. 2021 Jun;26(3):229–49. pmid:35251246
- 66. King-Dailey K, Frazier S, Bressler S, King-Wilson J. The Role of Nurse Practitioners in the Management of Heart Failure Patients and Programs. Curr Cardiol Rep. 2022 Dec;24(12):1945–56. pmid:36434405
- 67. Parent M, Leclerc J, O’Meara E, Barrette R, Lévesque S, Parent MC, et al. Clinical Heart fAilure Management Program: Changing the practice by partnering primary care and specialists (CHAMP-HF). IJC Heart Vasc. 2024 Feb;50:101330. pmid:38298468
- 68. Zavaleta-Monestel E, Arguedas-Chacón S, Quirós-Romero A, Chaverri-Fernández JM, Serrano-Arias B, Díaz-Madriz JP, et al. Optimizing Heart Failure Management: A Review of the Clinical Pharmacist Integration to the Multidisciplinary Health Care Team. Int J Heart Fail. 2024;6(1):1. pmid:38303921
- 69. Bonner A, Havas K, Stone C, Abel J, Barnes M, Tam V, et al. A multimorbidity nurse practitioner-led clinic: Evaluation of health outcomes. Collegian. 2020 Aug;27(4):430–6.
- 70. Charteris EJ, Pounds B. A nurse practitioner–led effort to reduce 30-day heart failure readmissions. J Am Assoc Nurse Pract. 2020 Nov;32(11):738–44. pmid:32740331
- 71. Crowther M. Optimal Management of Outpatients With Heart Failure Using Advanced Practice Nurses in a Hospital‐Based Heart Failure Center. J Am Acad Nurse Pract. 2003 Jun;15(6):260–5. pmid:12861892
- 72. Kuo YF, Adhikari D, Eke CG, Goodwin JS, Raji MA. Processes and Outcomes of Congestive Heart Failure Care by Different Types of Primary Care Models. J Card Fail. 2018 Jan;24(1):9–18. pmid:28870732
- 73. Lowery J, Hopp F, Subramanian U, Wiitala W, Welsh DE, Larkin A, et al. Evaluation of a Nurse Practitioner Disease Management Model for Chronic Heart Failure: A Multi‐Site Implementation Study. Congest Heart Fail. 2012 Jan;18(1):64–71. pmid:22277180
- 74. Stromberg A. Nurse-led heart failure clinics improve survival and self-care behaviour in patients with heart failureResults from a prospective, randomised trial. Eur Heart J. 2003 Jun;24(11):1014–23. pmid:12788301
- 75. Bensimhon D, Weintraub WS, Peacock WF, Alexy T, McLean D, Haas D, et al. Reduced Heart Failure-Related Healthcare Costs with Furoscix Versus in-Hospital Intravenous Diuresis in Heart Failure Patients: The FREEDOM-HF Study. Future Cardiol. 2023 Jun;19(8):385–96.
- 76. Civera J, Minana G, de la Espriella R, Santas E, Sastre C, Mollar A, et al. Venous Leg Compression for Tissue Decongestion in Patients With Worsening Congestive Heart Failure. Front Cardiovasc Med. 2022;9(101653388):847450. pmid:35872894
- 77. Gilotra NA, Princewill O, Marino B, Okwuosa IS, Chasler J, Almansa J, et al. Efficacy of Intravenous Furosemide Versus a Novel, pH-Neutral Furosemide Formulation Administered Subcutaneously in Outpatients With Worsening Heart Failure. JACC Heart Fail. 2018;6(1):65–70.
- 78. Greene SJ, Mentz RJ, Felker GM. Outpatient Worsening Heart Failure as a Target for Therapy: A Review. JAMA Cardiol. 2018;3(3):252–9. pmid:29387880
- 79.
National Guideline Centre (UK). Chronic Heart Failure in Adults: Diagnosis and Management. [Internet]. National Institute for Health and Care Excellence (NICE); 2018. Available from: https://www.ncbi.nlm.nih.gov/books/NBK536077/
- 80. Scherer RW, Meerpohl JJ, Pfeifer N, Schmucker C, Schwarzer G, Von Elm E. Full publication of results initially presented in abstracts. Cochrane Methodology Review Group, editor. Cochrane Database Syst Rev [Internet]. 2018 Nov 20 [cited 2024 Jul 29];2018(11). Available from: http://doi.wiley.com/10.1002/14651858.MR000005.pub4
- 81. Konstam MA. The Journey Toward Advances in Diuretics Management: Quite Far and Not Far Enough. J Card Fail. 2020;26(9):802–5. pmid:32829018