Resident-led Quality Improvement Initiative To Increase GDMT Prescribing Prior To Hospital Discharge In Vulnerable Patients With Heart Failure

Introduction Guideline-directed medical therapy (GDMT) at discharge is a quality metric intended to reflect the care provided for patients with heart failure and reduced ejection fraction (ADHF). However, the use of GDMT, particularly RAAS inhibitors, remains suboptimal. While HF quality improvement (QI) initiatives in hospitals are common, participation and engagement among residents are often limited. Hypothesis Creation of a house staff driven QI team will lead to an improvement in GDMT prescribing among patients with ADHF prior to discharge. Methods A QI team, comprised of internal medicine (IM) residents, a HF physician, and a hospital administrator, was formed at an urban, academic medical center. A SMART Aim was created, 3 key drivers were identified along with 5 interventions and change concepts (Figure 1). An anonymous electronic survey was administered to IM house staff to address perceptions and barriers to clinical implementation of GDMT and direct Plan-Do-Study-Act (PDSA) cycles. The first PDSA cycle consisted of biweekly, educational small group sessions with house staff and hospital medicine physicians. These sessions were conducted by the QI team residents and reviewed clinical indications in HFrEF specific populations and financial options for patients. A handout with prescribing pearls and references to clinical trials was also provided. The second PDSA cycle utilized an existing electronic medical record census report to identify patients with HFrEF currently admitted for ADHF. A standardized note suggesting ARNi prescription was written by the QI team. Interventions took place between January through March 2022. Results Baseline data revealed 56.9% of eligible patients were discharged on a RAAS inhibitor. From a total of 150 IM house staff, 26.7% completed the initial survey. For PDSA cycle 1, 22 small group educational sessions were completed yielding a total of 74 trainees approached over 6 weeks. For PDSA cycle 2, a total of 28 electronic notes in electronic health record of qualifying patients were entered. The rate of RAAS inhibitor use did not improve significantly after either PDSA cycle. Conclusion House staff driven initiatives in quality improvement activities represent an opportunity help identify and incorporate systems-based changes to improve patient care for individuals with ADHF. Future PDSA cycles may require direct interventions with multidisciplinary team engagement.