Implementation of a Nurse-led Titratoin of Guideline Directed Medical Therapy to Improve Outcomes in Heart Failure

Background: Heart failure with reduced ejection fraction (HFrEF) carries significant morbidity and mortality risks. Optimal use of guideline-directed medical therapy (GDMT) improves heart failure (HF) outcomes with a dose-dependent benefit. Multifactorial barriers delay the initiation and titration of this life-saving therapy. United States and European cardiology clinical practice guidelines for managing HF encourage a multidisciplinary approach. Meta-analysis of nurse-led titration (NLT) clinical trials demonstrates a reduction in HF hospitalization risk and mortality. NLT expands access to optimal HF care. United States adoption of NLT lags European centers. Local Problem: Due to the available local clinic infrastructure, face-to-face provider-based encounters for the stepwise titration of HF therapy have occurred quarterly rather than the recommended weekly to biweekly visits, resulting in delayed initiation and optimization of GDMT and increased risk of adverse outcomes. Methods: Utilizing the Johns Hopkins Evidence-based Practice Model as a guide, the quality improvement (QI) team developed and implemented a protocol for NLT of GDMT founded on evidence-based clinical practice guidelines. Interventions: Nurses were trained on the protocol and HFrEF management principles. Upon patient referral, nurses completed weekly outpatient telehealth encounters for adults with HFrEF to review symptoms, vital signs from home monitoring, and labs. Nurses then titrated GDMT per protocol based on physiologic parameters. Nurses followed patients until clinically stable on maximal tolerated GDMT. Weekly follow-up meetings were held with nurses. The QI project included encounter data for two months following patient enrollment. An executive summary was presented to the cardiology leaders to facilitate protocol refinement and broader implementation. Results: Among eligible patients (n=21), 10 were referred for NLT. Patients were followed for a mean of 6.7 weeks (SD 3.8) with 1.8 NLT encounters per patient (SD 2.1). The mean nurse time was 18.7 minutes (SD 9.5) per encounter. Nurses initiated 13 titrations of medical therapy. There was a significant increase in the use of the four pillars of GDMT (pre-intervention mean 2.1, post-intervention mean 3; t(9) = -2.86, p<.05). There were no significant safety concerns/adverse events. Nurses reported satisfaction and feelings of empowerment to practice at the top of their scope of practice. Lack of access to scheduling and telehealth software embedded in the electronic health record were persistent barriers to NLT. Conclusion: This QI project piloted a blueprint for NLT of GDMT within a rural branch of an urban multicenter cardiology practice to facilitate protocol refinement. It also established the business case for NLT and prepared for broader dissemination within the cardiology practice. NLT is part of a multidisciplinary approach to improve HF outcomes. It is a safe, evidence- based, cost-effective, and underutilized tool to optimize GDMT.