Internal Medicine Resident (PGY-2) University Hospital of Mirebalais Mirebalais, Haiti
Background: Heart failure is a major public health problem, contributing to significant morbidity and hospitalizations worldwide. Like many other countries, Haiti faces similar challenges. At the University Hospital of Mirebalais (UHM), Heart Failure places a substantial burden on the Internal Medicine department, with many patients experiencing prolonged hospitalizations. Recognizing length of stay as a key indicator of hospital efficiency and care quality, we initiated a quality improvement (QI) project aimed to reduce by 30 percentage points the proportion of patients with NYHA class III or IV Heart Failure hospitalized for more than 7 days.
METHODS AND RESULTS: We conducted an initial assessment using Excel to collect patient data, revealing an average hospital stay of 11 days. The indicator was defined as the percentage of patients with NYHA class III or IV Heart Failure hospitalized for more than 7 days in the Internal Medicine department at UHM between February 2024 and February 2025. The 7-day threshold was based on a previous survey conducted in sub-Saharan Africa. Then, a brainstorming session was held to build a fishbone diagram, followed by a Pareto chart to prioritize identified causes. We applied our institution’s QI model, using Plan-Do-Study-Act (PDSA) cycles. The first cycle focused on designing and implementing a diuretic administration protocol (Figure 1); the second involved clinical simulations to strengthen staff adherence to the protocol. Following the cycles, we conducted a follow-up phase to assess the sustainability of improvements. Patient length of stay was monitored biweekly using a run chart (Figure 2). At baseline, 26 out of 45 patients (57.77%) were hospitalized for more than 7 days. Following our interventions, no patients exceeded 7 days during PDSA cycles 1 and 2, representing a complete reduction. During the follow-up phase, a sustained improvement was observed, with only 4 out of 16 patients (25%) hospitalized for more than 7 days, representing a 32.7 percentage point reduction from baseline. Although two temporary setbacks occurred in late November and early December 2024, with increases to 34.6% and 50%, the overall trend remained consistently below 27.77% throughout the monitoring period. The final reduction was statistically significant compared to the baseline (57.77% vs. 27.59%; p = 0.0001 ; Chi-square)
Conclusion: This initiative, which included an aggressive yet safe diuretic protocol and clinical simulations, significantly reduced prolonged hospitalizations among heart failure patients. It highlights the need to pursue strategies for continuous improvement and can serve as a practical model for other countries facing similar healthcare challenges.
