Background: As the prevalence of patients admitted with a diagnosis of acute decompensated heart failure rises, hospitalists are at the forefront of delivering care for this complex patient population. Heart failure (HF) exacerbations are one of the leading causes of hospitalizations with high rates of readmissions and associated mortality. Evidence based studies show that optimizing guideline directed medical therapies (GDMT) for patients admitted with HF reduces readmissions, morbidity, and mortality. However, the degree to which patients are initiated on GDMT may vary amongst hospitalists and cardiologists due to numerous factors including comfort with prescribing and competing interests to reduce excess hospital days, but also minimize readmissions.
Purpose: This quality initiative aimed to adhere to best practices with HF care in the hospital setting through improved collaboration and care standardization amongst a multidisciplinary team on a HF unit. A new workflow was created to incorporate the HF team during daily afternoon rounds. A heart failure blurb or smart phrase was built within our electronic medical record (EMR) for hospitalists to use in their progress notes as a reminder about GDMT optimization.
Description: At our quaternary care academic medical center, patients with a diagnosis of advanced heart failure are cohorted to a dedicated HF unit, primarily admitted under hospitalists with cardiology and/or HF team consultation. As a care model unit with a high performing multidisciplinary team, daily interdisciplinary rounds and afternoon rounds are run by a lead hospitalist, nurse manager, medicine NPs or PAs, case managers, and a clinical pharmacist. Beginning in May 2023, afternoon rounds began incorporating the HF team. The unit team meets to review all patients on the floor and the HF team provides high level updates about the plan of care for the patients on the unit. This close communication translated to improved patient care and facilitated discharge planning. Since the initiation of this process, the HCAHPS survey results returned for patients on the unit have shown improvements in multiple domains including communication with doctors (22% top box scores YTD from 4% in 2022), communication with nurses (14% from 8%), discharge information (47% from 5%), and communication about medications (15% from 6%). By leveraging smart phrases in our EMR, a heart failure blurb was created to remind hospitalists of HF care standards. The blurb has blank sections prompting hospitalists to comment on weight changes, diuretics and GDMT. It also has a cue about the HF order set (which includes telemetry, daily standing weight, nutrition consult orders). Hospitalists were educated about this HF blurb and an educational GDMT lecture was provided by the heart failure team. Routine progress note audits were performed to give directed feedback and encourage compliance. Since the initiative, the use of GDMT in the hospital from the first quarter to the third quarter of the year have increased with higher rates of prescriptions for ARNI (21% from 17%), SGLT2 inhibitors (22% from 14%), MRA (25% from 21%), and loop diuretics (82% from 80%). During this time, the CMI adjusted length of stay for patients on the HF unit have maintained stable at 4.6 from 4.7 YTD, suggesting this process has not prolonged hospital days.
Conclusions: Optimizing inpatient GDMT and increasing collaboration amongst a multidisciplinary team on a HF unit have improved patient satisfaction and provided best standards of care.
