# Enhancing Adherence to Chronic Heart Failure Monitoring: A Student-Led Quality Improvement Project During Clinical Placement

## TL;DR

Medical students improved heart failure monitoring in a hospital by introducing a care bundle, leading to better adherence to guidelines.

## Contribution

A student-led quality improvement project successfully enhanced adherence to chronic heart failure monitoring standards in a hospital setting.

## Key findings

- Adherence to inpatient monitoring requirements improved significantly, reaching up to 86.8% after two PDSA cycles.
- Nutritional status, fluid status, and daily ECG monitoring showed the largest improvements in completion rates.
- The intervention was sustainable with minimal infrastructure and continued beyond the students' placement period.

## Abstract

Introduction: Heart failure (HF) poses a major clinical and economic burden within UK hospitals, with poor inpatient monitoring often undermining guideline-directed medical therapy. In the Acute Medical Unit (AMU) at Darent Valley Hospital, pre-intervention audits revealed suboptimal adherence to National Institute for Health and Care Excellence monitoring standards for chronic heart failure (CHF). The areas of monitoring include functional capacity, fluid status, cognitive status using the Glasgow Coma Scale, nutritional status, urea and electrolytes (U+Es) and the locally recommended daily 12-lead ECG within the first 24 hours of admission. CHF monitoring adherence was assessed by scoring completion of these six predefined parameters. Completion of fluid status monitoring and nutritional status was particularly poor. This five-month quality improvement project (QIP), led by medical students, aimed to improve adherence to inpatient monitoring requirements for patients presenting with acute CHF decompensation (acute-on-chronic HF) within the first 24 hours of admission by implementing a CHF care bundle.

Methods: Using the Plan-Do-Study-Act (PDSA) model, we conducted two iterative intervention cycles. Baseline data were collected from 19 patients, followed by 13 and 19 patients in subsequent cycles. The intervention involved distributing a simplified care bundle flowchart to staff working in the AMU and providing orientation. Quantitative adherence data were collected from electronic health records and bedside documentation.

Results: Results showed a significant improvement in adherence to inpatient monitoring requirements, from a baseline median of 50.9%-86.8% after the second PDSA cycle. From baseline, the completion of nutritional status assessment (+52.6%), daily 12-lead ECG (+63.2%) and fluid status monitoring (+52.6%) saw the largest improvements. Run-chart analysis revealed that monitoring adherence stabilised by Cycle 2.
Conclusion: This QIP demonstrates that cost-effective, low-resource, bundle-based interventions can enhance inpatient CHF monitoring, while showcasing the valuable role medical students can play in advancing sustainability initiatives within the NHS. Sustainability was supported by minimal reliance on additional infrastructure, enabling it to continue beyond the students’ placement period.