160 An audit of guideline directed medical therapy initiation for patients admitted to hospital for an acute decompensation of heart failure
Published Date: 02nd June 2023
Publication Authors: Chiong J
Introduction
Cardiovascular disease is the most common cause of death worldwide (1). Heart failure is a major contributor to this (2), with mortality rates particularly high in those hospitalised due to an acute decompensation (3). Approximately 1 in 4 patients admitted with worsening heart failure die or are readmitted within 30 days of discharge (4), resulting in significant morbidity and cost to the health service. Guideline directed medical therapy (GDMT), including beta blockers, ACE inhibitors, mineralocorticoid receptor antagonists (5), and more recently, SGLT-2 inhibitors (6) has shown to greatly improve patient outcomes. The European Society of Cardiology and National Institute for Health and Care Excellence recommend auditing the proportion of patients with heart failure who are prescribed GDMT in absence of contraindications as a quality indicator of patient care. The aim of this quality improvement project is to assess and improve the prescription rates of GDMT in patients with heart failure.
Materials and Methods
All patients discharged following an acute decompensation of heart failure with reduced ejection fraction (LVEF<40%) from hospitals in NHS Tayside over a two-week period were audited in the first cycle. Quality improvement interventions were designed and carried out using a DMAIC (Define, Measure, Analyse, Improve, Control) approach. Heart failure guidelines in the trust were redesigned and updated with input from the local heart failure service. This was made to be in line with most recent ESC guidance on initiating GDMT, with a particular emphasis on SGLT-2 inhibitor prescription. Over a two-week intervention period, new guidelines were widely circulated. These were made more readily available on the trust intranet and posters were placed in the acute medical unit, cardiology ward and coronary care unit. Following this, patients discharged with an acute decompensation of heart failure were re-audited over further two-week period and the interventions were evaluated. Data was collected from electronic patient records and analysed at the end of each cycle.
Results
A total of 47 patients over the 4-week audit period were discharged with a diagnosis of heart failure with reduced ejection fraction (LVEF <40%). Patients had a mean age of 69±13, were predominantly male (85%) and had a high prevalence of concurrent Type 2 diabetes mellitus (36%). There was no significant demographic or clinical characteristic differences between the pre and post intervention groups. In the baseline audit, most patients were appropriately discharged on an ACE-I (93%) and beta blocker (93%), however, there were lower rates of mineralocorticoid receptor antagonist (64%) and SGLT-2 inhibitor (50%) prescription in absence of contraindication. Following intervention, high rates of ACE-I (95%) and beta blocker (100%) prescriptions were maintained, whilst mineralocorticoid receptor antagonist (74%) and SGLT-2 inhibitor (74%, p=0.05) were notably higher. There were 32 documented instances of contraindications to GDMT prescription. The most common reasons for this were frailty (31%) and hypotension (18%).
Conclusion
In this two-cycle closed loop DMAIC audit and quality improvement project, we were able to demonstrate improvement in GDMT prescription rates for patients with heart failure through the use of a simple, cost-effective method, successfully implemented over a short period of time. Local heart failure services would benefit from increasing awareness, education and access to up-to-date guidelines in hospitals.
Chiong, J. et al. (2023). 160 An audit of guideline directed medical therapy initiation for patients admitted to hospital for an acute decompensation of heart failure. Heart. 109(Suppl. 3), pp.A187-A188. [Online]. Available at: https://doi.org/10.1136/heartjnl-2023-BCS.160 [Accessed 27 February 2024].
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