PSHP 2026 Residency Conference

This study evaluated provider adherence to the emergency department diuretic order set for patients admitted with a heart failure exacerbation, specifically assessing IV diuretic doses and timing of administration to optimize care.


This single-center, retrospective chart review at Thomas Jefferson University Hospital included patients identified via the electronic medical record between 4/1/2025 and 9/30/2025 who presented to the emergency department with heart failure, dyspnea, or fluid overload and received an IV loop diuretic. Those with a mean arterial pressure < 65, on dialysis, or missing data were excluded. Patients were classified as adherent or non-adherent based on the standardized ED admission order set. Non-adherent patients were further classified as either under- or overdosed in relation to the dosing recommended in the order set. The primary endpoint analyzed provider adherence incidence using descriptive statistics. Secondary endpoints—door-to-diuretic time, administration relative to timing of labs, and method of arrival—were analyzed using descriptive statistics and compared between groups using Fisher’s exact and Kruskal-Wallis tests.


A total of 210 patients were included; 54% (114/210) were male and 60% (125/210) were African American. Providers were non-adherent to the order set in 66% (139/210) of patients; 69% (96/139) of those were underdosed vs order set recommendations. 15% (31/210) of patients had a door-to-diuretic time of ≤100 minutes, and 90% (190/210) had their first IV diuretic after labs resulted. Fisher’s exact test (p ≤ .001) showed a significant association between door-to-diuretic time and diuretics being given before labs resulted. Kruskal-Wallis test found no significant difference in door-to-diuretic time across the three methods of arrival to the ED (ambulatory, fire rescue/emergency medical services, unknown), χ2 ([2], N = 210) = 5.411, p = .067.


Provider adherence to the emergency department diuretic order set was low, with frequent underdosing and delays in treatment. Early diuretic administration was uncommon, and many providers waited to treat until after labs resulted, prolonging door-to-diuretic time. These findings highlight opportunities to improve adherence and reduce delays in dosing to optimize outcomes in heart failure patients experiencing an exacerbation.


IRB Approval: Exempt


Authors: Kaylee Morosky, PharmD & Margo Graybill, PharmD; Thomas Jefferson University Hospital (TJUH), Philadelphia, PA - Department of Pharmacy