Fluid Balance, Diuretic Responsiveness, and Care Quality: Impact on Ambulation, Cannula Safety, Catheter Management, and Nutritional Status

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Background: The hematocrit-to-hemoglobin ratio (HHR) is a simple, low-effort, and inexpensive bedside tool that can distinguish between hemodilution (HHR <3) and hemoconcentration (HHR ≥3). Hemodilution has been associated with worse clinical outcomes in patients with heart failure, renal disease, cirrhosis, or sepsis. Early de-resuscitation and diuretic responsiveness, leading to a negative fluid balance, may improve the quality of care. However, the relationship between fluid balance status and nursing-sensitive outcomes such as early ambulation, peripheral intravenous complications, Foley catheter duration, catheter-associated urinary tract infections (CAUTI), nutritional well-being, and the effectiveness of de-resuscitation and diuretics remains to be clarified. Aim: The aim of this study is to determine whether early de-resuscitation, diuretic responsiveness, and early negative fluid balance improve the quality of treatment. Specifically, the study explores the relationship between fluid balance status (hemodilution vs. hemoconcentration) and early ambulation, peripheral intravenous problems, the length of Foley catheter use, the risk of catheter-associated urinary tract infections (CAUTI), nutritional well-being, and whether de-resuscitation and diuretics improve nursing care. Methods: This was a retrospective group analysis of patients treated at Royal Medical Services hospitals between February 2021 and November 2025. Participants were adults who visited an internist and had available hematocrit/hemoglobin (Hct/Hgb) data, daily fluid balance records, and nursing documentation. Patients with missing data, persistent bleeding, or end-stage renal disease (ESRD) on continuous renal replacement therapy (CRRT) were excluded. Results: A total of 847 patients were analyzed (mean age 68.4±14.2 years; 54.6% males). Among them, 412 cases had a hemodilution rate (HHR) of less than three. Hemodilution was significantly associated with worse outcomes, including delayed ambulation (>48 hours) (56.8% vs. 38.4%, p<0.001), peripheral intravenous complications (43.2% vs. 18.9%, p<0.001), longer Foley catheter duration (median 5 days vs. 3 days, p<0.001), higher rate of catheter-associated urinary tract infections (16.5% vs. 8.0%, p<0.001), poor oral intake (42.7% vs. 24.6%, p<0.001), and greater decline in albumin levels (0.6±0.4 g/dL vs. 0.3±0.3 g/dL, p<0.001). De-resuscitation (achieving a negative fluid balance by day 3) was performed in 38.2% of diluted patients and was associated with better outcomes. A HHR value of less than three suggests that de-resuscitation would be successful when the Furosemide Refractoriness Index is less than 0.5 (odds ratio = 2.84, 95% confidence interval = 1.92–4.20). Outcomes were improved when de-resuscitation and diuretic procedures were completed in a timely manner. Conclusion: HHR is a simple and inexpensive bedside device that may assist with fluid management. Hemodilution (HHR <3) is associated with worse clinical and nursing outcomes, while early de-resuscitation and diuretic responsiveness—particularly when the Furosemide Refractoriness Index is less than 0.5—are associated with improved outcomes. Timely de-resuscitation and diuretic procedures may enhance the quality of treatment in this