Optimizing Heart Failure Management Development And Implementation Of A Standardized Discharge Checklist For Heart Failure Patients In A Tertiary Care Hospital In Pakistan

Quality improvement project

Abstract

Background: Heart failure (HF) is a major contributor to hospital admissions, mortality, and healthcare costs globally, particularly in low- and middle-income countries such as Pakistan. Despite the availability of evidence-based guidelines from the European Society of Cardiology (ESC 2023) and NICE (NG106), real-world implementation in Pakistani tertiary care hospitals remains inconsistent. Discharge practices are often fragmented, lacking structured documentation, comprehensive therapy optimization, and proper follow-up planning. These gaps lead to high rates of 30-day readmissions and poor post-discharge outcomes. In cardiology department of Ayub Teaching Hospital, Abbottabad, the need for a standardized and systematic approach to discharge planning for HF patients was identified as a critical quality improvement priority.

Objectives: The primary aim of this project was to develop and implement a structured, evidence-based discharge checklist for heart failure patients in cardiology department of Ayub teaching hospital. The objectives were To standardize the discharge process based on international guidelines (ESC 2023 and NICE NG106);To improve the documentation of key clinical parameters ;To enhance prescription of guideline-directed medical therapy (GDMT);To ensure appropriate patient education and timely post-discharge follow-up;To reduce 30-day heart failure-related readmission rates

Materials and Methods: A retrospective baseline audit was conducted from 01 July 2024 to August 30, 2024, involving 125 patients admitted with a primary diagnosis of heart failure. Key discharge elements were evaluated, including documentation of HF type, NYHA class, left ventricular ejection fraction (LVEF), completeness of GDMT, loop diuretic dosing, patient education, follow-up planning, and discharge communication with primary care providers. A standardized discharge checklist was then developed using the NICE NG106 and ESC 2023 guidelines.3,4 In the first Plan-Do-Study-Act (PDSA) cycle, the checklist was piloted in cardiology unit from September 10 to 24, 2024. During this phase, 28 patients with heart failure were discharged using the checklist. House officers and residents were trained in its use, and compliance was monitored daily. Post-intervention data were collected and compared with baseline figures. Chi-square statistical analysis was applied to assess significance.

Results: Implementation of the checklist led to significant improvements in all assessed discharge parameters. The documentation of HF type increased from 59.2% to 85.7%, NYHA class and LVEF from 52.8% to 82.1%, and complete GDMT prescription from 40.8% to 67.8%. Patient education documentation improved from 31.2% to 60.7%, and planned follow-up within 14 days rose from 37.6% to 78.5%. Communication with primary care providers increased from 26.4% to 57.1%. The 30-day HF-related readmission rate showed a downward trend, decreasing from 33.6% to 25.0%. All improvements, except readmission (which was preliminary), were statistically significant (p < 0.05).

Conclusion: The introduction of a standardized discharge checklist significantly improved discharge documentation, GDMT prescription, patient education, and care coordination for heart failure patients. The intervention showed early promise in reducing readmission rates and demonstrated the feasibility of integrating evidence-based guidelines into routine clinical practice, even in resource-limited settings. Hospital-wide implementation and longer-term follow-up are now underway to sustain and expand these improvements. This QIP highlights how simple, structured interventions can yield meaningful improvements in quality of care and patient outcomes.