Internal Medicine Resident (PGY-2) University Hospital of Mirebalais Mirebalais, Haiti
Background: Heart failure with reduced ejection fraction (HFrEF) is a progressive condition causing high global rates of morbidity, mortality, and hospital readmissions. Management includes four key drug classes known as guideline-directed medical therapy (GDMT), demonstrated to improve survival and reduce morbidity. However, GDMT at target doses remains underutilized in clinical practice. Hospitalization for HFrEF provides a key opportunity to optimize therapy under close monitoring; however, this is often underutilized, including at the University Hospital of Mirebalais (UHM). To address this, we initiated a quality improvement project aiming to increase to ≥70% the proportion of hospitalized HFrEF patients discharged on optimized Angiotensin-converting enzyme inhibitor (ACEI) and beta-blocker therapy between February 2024 and March 2025.
METHODS AND RESULTS: An initial assessment measured ACEI and beta-blocker optimization rates in HFrEF patients. The project team held brainstorming sessions to identify and rank barriers to optimization based on frequency and clinical impact. The results were summarized in Pareto charts. Two Plan-Do-Study-Act (PDSA) cycles were implemented, involving developing a protocol for ACEI and beta-blocker optimization [Figure 1], training staff on GMDT, and engaging the medical team through communication. Data were collected periodically and tracked using run charts.
Initially, ACEI optimization was 7.14% (1/14), and beta-blockers 0.00% (0/14) [Figures 2]. After the first PDSA, optimization rates modestly increased to 9.09% (1/11) for both medications. Following the second PDSA, which emphasized clinical supervision and decision support, performance improved to 85.71% (6/7) for ACEIs and 57.14% (4/7) for beta-blockers. Over the following seven measurement periods, rates stayed above 70%, except for December 20–28, 2024, when beta-blocker optimization dropped to 50.00% (5/10) due to a temporary IV furosemide shortage resulting in persistent NYHA IV congestion. By March 2025, beta-blocker optimization reached 100% (8/8), and ACEI performance remained above target. Compared to baseline, final rates showed significant improvement: ACEIs (7.14% vs. 87.50%) and beta-blockers (0.00% vs. 100%) (p < 0.001 for both, Fisher’s exact test).
Conclusion: An aggressive in-hospital titration protocol and staff training led to improved achievement of target medication doses before discharge in patients with HFrEF. This real-world experience demonstrates that structured interventions can support effective titration of GDMT during hospitalization. When applied consistently, these approaches could help reduce readmissions and improve long-term outcomes.
