American Journal of Educational Research
ISSN (Print): 2327-6126 ISSN (Online): 2327-6150 Website: http://www.sciepub.com/journal/education Editor-in-chief: Ratko Pavlović
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American Journal of Educational Research. 2016, 4(6), 491-495
DOI: 10.12691/education-4-6-9
Open AccessArticle

A Clinical Audit Examining the Use of Furosemide by the London Ambulance Service

Joanna Shaw1, , Mark Whitbread2 and Rachael T Fothergill1

1Clinical Audit and Research Unit, London Ambulance Service NHS Trust, London, UK

2Medical Directorate, London Ambulance Service NHS Trust, London, UK

Pub. Date: May 03, 2016

Cite this paper:
Joanna Shaw, Mark Whitbread and Rachael T Fothergill. A Clinical Audit Examining the Use of Furosemide by the London Ambulance Service. American Journal of Educational Research. 2016; 4(6):491-495. doi: 10.12691/education-4-6-9

Abstract

In July 2001, the London Ambulance Service NHS Trust (LAS) introduced furosemide for use by paramedics to treat pulmonary edema secondary to left ventricular failure (LVF). In 2002, a clinical audit identified that paramedics had difficulty distinguishing pulmonary edema secondary to LVF from other conditions, and also had issues with drug administration records. As a result, LAS training packages were reviewed in line with the drug dosage guidelines, which were reissued nationally in 2006. Later publications on furosemide use highlighted some concerns about the accuracy of pre-hospital diagnosis of pulmonary edema. A retrospective re-audit was conducted for 246 cases where furosemide was administered. All clinical records were assessed by clinical audit staff and a clinical advisor, who examined appropriateness of furosemide use in line with the national guidelines. Patient diagnoses upon arrival at hospital were requested for every patient; 166 patient diagnoses were received. The re-audit findings showed patients administered furosemide received a thorough assessment of their observations and appropriate drug administration records, h. owever, only 46% of patients received a hospital diagnosis that indicated pre-hospital furosemide administration was appropriate. The re-audit results indicated the concerns identified in the initial LAS furosemide clinical audit, relating to drug documentation and dosage, were resolved. However, the review of the appropriateness of administration of furosemide demonstrated that it was often used when not indicated. This low figure of diagnostic accuracy supports published evidence, and further demonstrates the difficulties of identifying pulmonary edema secondary to LVF in the pre-hospital setting. As a result of the potential side effects of administering furosemide when it is not indicated the LAS made the decision to withdraw furosemide as a treatment for pulmonary edema.

Keywords:
furosemide emergency medical services pulmonary edema heart failure

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References:

[1]  Joint Royal Colleges Ambulance Liaison Committee and The Ambulance Service Association, UK Ambulance Service Clinical Practice Guidelines, in Specific Treatment Options. Pulmonary Oedema, J.D. Fisher, S.N. Brown, and M.W. Cooke, Editors. 2006, IHCD: Coventry.
 
[2]  Acute heart failure with dyspnoea: initial treatment. Furosemide and trinitrine, despite the lack of a proven survival benefit. Prescrire Int, 2011. 20(117): p. 156-60.
 
[3]  Jaronik, J., et al., Evaluation of prehospital use of furosemide in patients with respiratory distress. Prehosp Emerg Care, 2006. 10(2): p. 194-7.
 
[4]  Dikshit, K., et al., Renal and extrarenal hemodynamic effects of furosemide in congestive heart failure after acute myocardial infarction. N Engl J Med, 1973. 288(21): p. 1087-90.
 
[5]  European Resuscitation Council, Part 6: advanced cardiovascular life support. Section 6: pharmacology II: agents to optimize cardiac output and blood pressure. European Resuscitation Council. Resuscitation, 2000. 46(1-3): p. 155-62.
 
[6]  Hoffman, J.R. and S. Reynolds, Comparison of nitroglycerin, morphine and furosemide in treatment of presumed pre-hospital pulmonary edema. Chest, 1987. 92(4): p. 586-93.
 
[7]  Corey, E.C., Improving CHF care. A new algorithm for prehospital treatment. Jems, 2007. 32(4): p. 68-74.
 
[8]  Johnson, A. and K. Mackway-Jones, Frusemide or nitrates in acute left ventricular failure. Emergency Medicine Journal, 2001. 18(1): p. 59-60.
 
[9]  Collins, S.P., et al., International variations in the clinical, diagnostic, and treatment characteristics of emergency department patients with acute heart failure syndromes. Eur J Heart Fail, 2010. 12(11): p. 1253-60.
 
[10]  Hampton, J.R., Results of clinical trials with diuretics in heart failure. Br Heart J, 1994. 72(2 Suppl): p. S68-72.
 
[11]  Cotter, G., et al., Randomised trial of high-dose isosorbide dinitrate plus low-dose furosemide versus high-dose furosemide plus low-dose isosorbide dinitrate in severe pulmonary oedema. Lancet, 1998. 351(9100): p. 389-93.
 
[12]  Tresch, D.D., et al., Out-of-hospital pulmonary edema: diagnosis and treatment. Ann Emerg Med, 1983. 12(9): p. 533-537.
 
[13]  Mosesso, V.N., Jr., et al., Prehospital therapy for acute congestive heart failure: state of the art. Prehosp Emerg Care, 2003. 7(1): p. 13-23.
 
[14]  Eckstein, M. and D. Suyehara, Ability of paramedics to treat patients with congestive heart failure via standing field treatment protocols. Am J Emerg Med, 2002. 20(1): p. 23-5.
 
[15]  Shapiro, S.E., Evidence review: emergency medical services treatment of patients with congestive heart failure/acute pulmonary edema: do risks outweigh benefits? J Emerg Nurs, 2005. 31(1): p. 51-7; quiz 118-9.
 
[16]  McKinney, J., J. Brywczynski, and C.M. Slovis, Med under scrutiny: the declining roles of furosemide, morphine & beta blockers in prehospital care. Jems, 2009. 34(1): p. 10-2.
 
[17]  17.Wang, C.S., et al., Does this dyspneic patient in the emergency department have congestive heart failure? Jama, 2005. 294(15): p. 1944-56.
 
[18]  Grayson, S. and W.E. Gandy, CHF treatment: is furosemide on the way out? Rethinking the pulmonary edema cocktail. EMS World, 2012. 41(6): p. 20-4.
 
[19]  London Ambulance Service NHS Trust. Providing an emergency response. 2013 [cited 2014 04/12/2014]; Available from: http://www.londonambulance.nhs.uk/about_us/what_we_do/providing_an_emergency_respons.aspx.
 
[20]  Raosoft. Sample size calculator. 2004 [cited 2014 10/12/2014]; Available from: http://www.raosoft.com/samplesize.html.
 
[21]  Cone, D.C., Knowledge translation in the emergency medical services: a research agenda for advancing prehospital care. Acad Emerg Med, 2007. 14(11): p. 1052-7.
 
[22]  Francis, G.S., et al., Acute vasoconstrictor response to intravenous furosemide in patients with chronic congestive heart failure. Activation of the neurohumoral axis. Ann Intern Med, 1985. 103(1): p. 1-6.
 
[23]  Northridge, D., Frusemide or nitrates for acute heart failure? Lancet, 1996. 347(9002): p. 667-8.
 
[24]  Hubble, M.W., et al., Effectiveness of prehospital continuous positive airway pressure in the management of acute pulmonary edema. Prehosp Emerg Care, 2006. 10(4): p. 430-9.
 
[25]  Kosowsky, J.M., et al., Prehospital use of continuous positive airway pressure (CPAP) for presumed pulmonary edema: a preliminary case series. Prehosp Emerg Care, 2001. 5(2): p. 190-6.
 
[26]  Marchetta, M., et al., Prehospital CPAP reduced need for intubation in respiratory emergencies. Journal of Emergency Medical Services, 2007. 32(3): p. 54.
 
[27]  Williams, B., et al., When pressure is positive: a literature review of the prehospital use of continuous positive airway pressure. Prehosp Disaster Med, 2013. 28(1): p. 52-60.
 
[28]  Gardtman, M., et al., Has an intensified treatment in the ambulance of patients with acute severe left heart failure improved the outcome? Eur J Emerg Med, 2000. 7(1): p. 15-24.
 
[29]  Oherrick, M.R., Prehospital use of continuous positive airway pressure: implications for the emergency department. J Emerg Nurs, 2009. 35(4): p. 326-9.