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

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 reaudit 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.