Improving outcomes of systolic heart failure:

The feasibility of using a pre-discharge checklist in a tertiary centre

Arwa Balharth,1 Maha Al Ammari,1,3 Mohammed AlQahtani,2,4 Rajkumar Rajendram2,4
Departments of Pharmacy1 and Medicine2 King Abdulaziz Medical City (KAMC), Ministry of National Guard - Health Affairs, King Abdullah
International Medical Research Center, Riyadh, Saudi Arabia,

Colleges of Pharmacy3 and Medicine,4 King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

Introduction: Systolic heart failure (SHF) causes significant morbidity and mortality.[1] Regrettably, an audit of
patients with SHF whom were admitted to King Abdulaziz Medical City, Riyadh (KAMCR) revealed suboptimal use
of evidence-based therapies.[2] To address this, a checklist was designed. This incorporated the interventions
recommended by the Saudi Heart Association guidelines for heart failure.[1] The aim of this study was to
determine the feasibility of using a checklist in this setting and evaluate the impact its use on physicians’ orders
and readmissions.

Methods: The treatment and outcomes of patients with SHF were prospectively audited at KAMCR between
01/09/19 and 30/11/19. Prior to discharging any patient with SHF, physicians were asked to complete the paper
checklist. This checklist included a section on medications which should be considered. To evaluate the impact of
this initiative, data on demographics, comorbidities, orders (pre-admission & on discharge), and re-admissions
were collected. These data were extracted from the checklists and the electronic medical records of all patients
with SHF for whom the checklist was used. Data were analysed using ExCel 2016 (Microsoft, USA). Categorical
data, presented as frequency and percentage, were compared using the χ2 test (p < 0.05 was considered
significant).

Results: During the quality improvement initiative the checklist was completed for 29 patients (7 women, 22
men; average age 74 years, SD ± 12). On discharge the primary diagnosis was SHF in 44.8% of the cohort.
Comorbidities included hypertension (96%), diabetes mellitus (68%), ischemic heart disease (37%), chronic kidney
disease (34%) and hyperlipidaemia (34%). Eleven patients attended their follow up appointment; 18 did not. Five
(17.2%) were admitted in the month prior to the index admission. Two (6.9% of the entire cohort; χ2 1.4622;
p=0.226583) were readmitted within 30 days. There were no deaths within 30 days in this cohort. Beta-blockers
and lipid lowering therapy were most commonly prescribed appropriately. Aldosterone antagonists were least
commonly prescribed when indicated. Table 1 and Figure 1 highlight the impact of the quality improvement
initiative on the appropriate prescription of medications for SHF. They the show the medications ordered pre-
admission and on discharge in the context of the medications which were indicated. Whilst the appropriate
prescription of all medications except nitrates and anticoagulation increased, the difference did not achieve
statistical significance.
Table 1. The impact of the pre-discharge checklist on the prescription of medications for systolic heart failure

Medication Indicated (n; %) Admission (n; Discharge (n; % χ2; p

% of indicated) % of indicated)

Angiotensin converting 28 (29; 96.5%) 13 (28; 46.4%) 17 (28; 60.7%) 0.348;

enzyme inhibitor (ACE I) / 0.55
Angiotensin II receptor
blocker (ARB) or both

Aldosterone antagonist 10 (29; 24%) 7 (10; 70%) 8 (10; 80%) 0.0381;

(AA) 0.84
Beta blocker (BB) 27 (29; 93%) 21 (27; 77.7%) 27 (27; 100%) 0.398;
0.52
Digoxin 1 (29; 3.44%) 1 (1; 100%) 1 (1; 100%) 0; 1

Loop diuretic 28 (29; 96.5%) 21 (28; 75%) 24 (28; 85.7%) 0.111;

0.739

Nitrate 6 (6; 100%) 6 (6; 100%) 5 (6; 83.3%) 0.0475;

0.82

Anticoagulation 1 (29; 3.44%) 1 (1; 100%) 1 (1; 100%) 0; 1

Lipid lowering therapy 28 (29; 96.5%) 26 (28; 92.8%) 28 (28; 100%) 0.037;
(LLT) 0.84

Conclusion: The use of a pre-discharge checklist is feasible but did not reduce Readmissions. The appropriate
prescription of medications increased but did not achieve statistical significance. However, the present feasibility
study was not powered to show this. This initiative will be sustained by incorporation of the checklist into the
electronic medical records. A ‘force function’ can then applied to ensure that the checklist will be completed
prior to the discharge of any patient admitted with SHF.

References
1. AlHabeeb W, Al-Ayoubi F, AlGhalayini K et al. Saudi Heart Association (SHA) guidelines for the management of heart failure. J
Saudi Heart Assoc. 2019;31:204-253.
2. Alqahtani M, Alanazi T, Binsalih S et al. Characteristics of Saudi patients with congestive heart failure and adherence to
management guidelines in a tertiary hospital in Riyadh. Ann Saudi Med. 2012;32:583-7.
 Improving outcomes of systolic heart failure:
The feasibility of using a pre-discharge checklist in a tertiary centre
Arwa Balharth,1 Maha Al Ammari,1,3 Mohammed AlQahtani,2,4 Rajkumar Rajendram2,4
Departments of Pharmacy1 and Medicine2 King Abdulaziz Medical City (KAMC), Ministry of National Guard - Health Affairs, King Abdullah
International Medical Research Center, Riyadh, Saudi Arabia,

Colleges of Pharmacy3 and Medicine,4 King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

Figure 1. The effect of a pre-discharge checklist on medications for SHF ordered on admission and on discharge

30

25

20

15

10

0
ACE / ARB AA BB Loop diuretic Nitrate LLT

Indicated Admission Discharge