Providing effective discharge instructions, appropriate dose uptitration, education regarding heart failure (HF) monitoring, and strict follow-up have all been shown to decrease readmissions for HF but are all underutilized. The authors developed and evaluated the impact of a quality-improvement HF checklist as a tool to remind physicians to improve quality of care in HF patients. The checklist was used in randomly selected patients admitted with a primary diagnosis of acute decompensated HF. It included documentation regarding medications and dose uptitration, relevant counseling, and follow-up instructions at discharge. The checklist was used in 48 patients, and this checklist group was compared with 48 patients as a randomly selected control group. Higher proportions of patients were taking angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) in the checklist group compared with the control group (40 of 48 vs 23 of 48, P<.001). Compared with the controls, the rate of dose uptitration for β-blockers and/or ACE inhibitors/ARBs was more common in the checklist group (4 of 48 vs 21 of 48, P<.001). Both 30-day (19% to 6%) and 6-month (42% to 23%) readmissions were lower in the checklist group. The use of an HF checklist was associated with better quality of care and decreased readmission rates for patients admitted with HF.

Background: Approximately 33% to 40% of older adults with heart failure are re-hospitalized within three months of discharge. The 6 month readmission rate is as high as 50%. Studies have shown that upward titration of ACE I, ARB and beta-blockers after discharge resulted in reduced hospital re-admission rates, improved functional capacity and quality of life. In our quality improvement project two groups of patients admitted with primary diagnoses of CHF were studied. A discharge checklist was developed for the second group and its effect on dose titration and readmissions was studied. Methods: For the first group, all patients readmitted within 3 months for CHF from April 1, 2007 to December 31, 2007 were identified. The primary end point was the difference in dosage of ACE I/ARB and B- blockers between discharge and readmission. For the second group a CHF discharge checklist was used randomly in patients admitted with primary diagnoses of CHF from August 2008 to October 2009. Checklist included documentation regarding dose titration, relevant counselling, education and follow up instructions. Results: The first group had 127 readmissions for CHF within 3 months of discharge. The second had 48 patients in which CHF discharge checklist was used. The characteristics of two populations is shown in the Table. Second group readmissions for CHF were decreased after using the checklist from 68% (15/22) to 36% (8/22, p = 0.3). Compared to prior to using the checklist, the total number of readmissions within 6 months of discharge were reduced significantly from 25 to 9 (p = 0.04). Up titration of diuretics in the hospital was associated with decreased readmissions (p=0.07, 4/14 vs 0/8). Conclusion: The use of CHF discharge checklist significantly improves dose titration of heart failure medications and decreases the total number of readmissions due to CHF. Furthermore among drug dose titration, up titration of diuretics tend to decrease CHF readmissions. Baseline characteristics of the two study groups and effect of discharge checklist on dose titration Baseline characteristic Study group 1 Study group 2 (discharge checklist) p - value Age (mean +/− SD) in years 75.94 +/− 13.1 75.97 +/− 13.1 CHF readmissions 180 of 318 25 of 48 0.8 Women 70 of 127 21 of 48 0.47 Dose titration of beta blocker 16 of 127 17 of 48 0.008 Dose titration of ACE I/ARB 7 of 127 7 of 48 0.07 Dose titration of diuretic 16 of 127 11 of 48 0.17 Dose titration in beta blocker + ACE I/ARB 19 of 127 21 of 48 0.004 Dose titration in beta blocker + ACE I/ARB + diuretic 31 of 127 27 of 48 0.009

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