Assessment Of Diuresis Related Documentation In Acute Heart Failure Exacerbation Admissions: A Retrospective Observational Study

Introduction

Acute heart failure exacerbation is a common cause of hospitalization and often requires intravenous (IV) diuresis for symptom relief and decongestion. Because assessment of volume status can be subjective, objective measures such as urine output, fluid balance, daily weights, and clinician documentation of response are important in guiding treatment decisions. Incomplete documentation of these measures may limit assessment of diuretic response and contribute to variability in inpatient heart failure care. This study evaluated baseline diuresis-related documentation practices in patients admitted with acute heart failure exacerbation at a community hospital and identified areas for improvement.

Methods

We performed a retrospective chart review of all hospital admissions carrying a heart failure diagnosis over a 30-day period at Henry Ford Rochester Hospital. The initial dataset included 59 admissions. After excluding patients who did not have acute heart failure exacerbation as the primary reason for admission and those who did not receive IV diuresis, 36 admissions were included in the final cohort. Using physician orders and chart documentation, we assessed whether daily weights were ordered, whether weights were documented on any hospital day and on more than half of hospital days, whether intake and output (I&O) monitoring was ordered, whether I&O documentation was present on any hospital day and on more than half of hospital days, and whether response to diuresis was documented in the chart. Descriptive statistics were used.

Results

Among the 36 included admissions, daily weights were ordered in 17 patients (47.2%). Daily weights were documented on at least one hospital day in 20 patients (55.6%) and on more than half of hospital days in 7 patients (19.4%). I&O monitoring was ordered in 20 patients (55.6%). I&O documentation was present on at least one hospital day in 22 patients (61.1%) and on more than half of hospital days in 16 patients (44.4%). Response to diuresis was documented in 5 patients (13.9%). These findings demonstrate substantial gaps in documentation of core measures used to assess response to IV diuresis in acute heart failure exacerbation admissions.

Conclusions

In this retrospective single-center study of patients admitted with acute heart failure exacerbation, inconsistent adherence to basic diuresis-related monitoring and documentation was observed. Although all patients in the study received IV diuresis, fewer than half had daily weights ordered, and only a small proportion had weights documented on most hospital days. Intake and output monitoring was more consistently documented but remained incomplete, while documentation of clinical response to diuresis was rare. These findings are consistent with prior studies showing that routine fluid balance monitoring is often difficult to maintain in real-world inpatient settings and suggest that this gap is not limited to a single institution or care model. Our results also highlight differences between documentation elements, with tasks requiring more coordination or clinician synthesis appearing less likely to be completed.

Accurate assessment of diuretic response is clinically important because treatment decisions depend on reliable daily weights, fluid balance, and response assessment. In practice, these foundational data were inconsistently captured in our cohort, which may limit the ability to make informed treatment adjustments. The gaps identified suggest several feasible interventions, including a standardized heart failure order set that automatically includes daily weights and I&O monitoring, as well as integrating these measures into routine nursing workflow as mandatory charting tasks. This study provides a baseline assessment identifying high-yield targets for improvement. Limitations include small sample size, single-center design, and reliance on documentation rather than confirmed bedside practice. Overall, these findings highlight opportunities to improve the reliability of fundamental care processes in hospitalized heart failure patients.