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June 5, 2026Heart & Lung
Implementation of an emergency department electronic interruptive alert to guide intravenous diuretic dosing in acute decompensated heart failure
Key result
ED clinical decision support alerts for IV diuretics in ADHF achieve ~74% clinician acceptance.
- n=223
Why the study?
Appropriate initial dosing of IV loop diuretics in the ED remains challenging in ADHF, particularly for patients receiving chronic outpatient diuretics.
Does an electronic clinical decision support alert improve guideline-concordant intravenous diuretic dosing in patients with acute decompensated heart failure in the emergency department?
Key Points
- This research aims to assess the acceptance of an electronic alert designed to guide diuretic dosing in acute decompensated heart failure.
- Conducted a retrospective study of ED encounters between May 6 and December 6, 2024, using a CDS alert for diuretic dosing.
- Evaluated clinician acceptance of the alert-recommended diuretic action as the primary outcome.
- Used univariable logistic regression with Firth estimation to identify predictors of alert acceptance.
- Among 223 eligible ED encounters, 164 (73.5%) accepted the alert recommendation.
- Accepting alerts was associated with higher home furosemide doses and greater renal dysfunction (serum creatinine 1.47 vs 1.31 mg/dL).
- Predictors of alert acceptance included higher home diuretic dose (OR 1.01), elevated serum creatinine (OR 1.6), and elevated blood urea nitrogen (OR 1.02).
Study Design
Type
Observational (n=223)
Structured PICO
Does an electronic clinical decision support alert improve guideline-concordant intravenous diuretic dosing in patients with acute decompensated heart failure in the emergency department?
P
Population
223 emergency department encounters for patients with acute decompensated heart failure where an electronic clinical decision support alert for IV diuretic dosing fired.
E
Exposure
Electronic clinical decision support (CDS) alert prompting clinicians to administer at least twice a patient's home diuretic dose intravenously
C
Comparator
Encounters without alert acceptance (retrospective comparison)
O
Outcome
Clinician acceptance of the alert-recommended diuretic action
An emergency department-integrated clinical decision support alert for IV diuretic dosing in acute decompensated heart failure had high clinician uptake (73.5%), particularly for patients with greater illness severity and renal dysfunction.
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Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Our study did not assess whether following these digital alerts affected patient outcomes, such as fluid removal or length of hospital stay, but it does show that these tools are easily used in a clinical setting and affect treatment decisions. This is a critical first step toward broad clinical adoption in settings that treat critically ill cardiac patients.”
“These clinical decision support tools are most useful when they help clinicians make the right decision in the moment, rather than adding more noise to their busy workflows. These findings suggest that well-designed EHR CDS tools have potential to improve clinical decision making, even in the fast-paced environments of the emergency department and cardiac intensive care unit.”
Implication
Supports CDS feasibility in ED for sicker ADHF patients; leaves open impact on dosing concordance and outcomes.
Abstract
BACKGROUND: Intravenous (IV) loop diuretics are the cornerstone of therapy for acute decompensated heart failure (ADHF), yet appropriate initial dosing in the emergency department (ED), particularly for patients receiving chronic outpatient diuretics, remains challenging. To support guideline-recommended dosing, an electronic clinical decision support (CDS) alert was implemented to prompt clinicians to administer at least twice a patient's home diuretic dose intravenously. OBJECTIVES: To assess clinician acceptance of an ED-based CDS alert recommending guideline-concordant IV diuretic dosing and to identify predictors of alert acceptance. METHODS: We conducted a retrospective study of ED encounters between May 6 and December 6, 2024, in which the CDS alert fired for patients with ADHF. The primary outcome was clinician acceptance of the alert-recommended diuretic action. Univariable logistic regression with Firth estimation was used to evaluate predictors of alert acceptance. RESULTS: Among 223 eligible ED encounters, clinicians accepted the alert recommendation in 164 cases (73.5%). Median time from ED arrival to IV diuretic administration was similar between encounters with and without alert acceptance (2.16 [1.34-3.53] vs 2.35 [1.42-3.98] hours). Patients whose clinicians accepted the alert had higher home furosemide-equivalent doses and greater renal dysfunction, including higher serum creatinine (1.47 vs 1.31 mg/dL) and blood urea nitrogen (33.5 vs 28 mg/dL). Predictors of alert acceptance included higher home diuretic dose (OR 1.01), elevated serum creatinine (OR 1.6), elevated blood urea nitrogen (OR 1.02), and White race (OR 0.28). CONCLUSIONS: An ED-integrated diuretic CDS alert demonstrated high clinician uptake, with acceptance in nearly three-quarters of encounters. Acceptance was more likely among patients with greater illness severity, particularly renal dysfunction. These findings support the potential of CDS tools to optimize diuretic dosing for ADHF in the ED and warrant further evaluation of their impact on clinical outcomes.
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Cite This Study
Adie et al. (2026) conducted an observational in acute decompensated heart failure (n=223). Electronic clinical decision support (CDS) alert for IV diuretic dosing was evaluated on clinician acceptance of the alert-recommended diuretic action. An emergency department-integrated clinical decision support alert for intravenous diuretic dosing in acute decompensated heart failure was accepted by clinicians in 73.5% of encounters.