**Introduction / Hypothesis**
The purpose of this initiative was to improve patient heart failure management in guideline-directed medical therapy (GDMT) through provider entered orders and RN (Registered Nurse) protocol led medication titration with Electronic Health Record (EHR) enhancements. Improved heart failure management prevented hospital admissions. 
Heart failure (HF) exacerbations occur suddenly. Early recognition of symptoms reduces hospitalizations and increases survival. A collaborative, multidisciplinary approach to symptom assessment and guideline-directed medication titration reduced the need for hospital admission within 30 days of enrollment in the medication titration program. Expansion of GDMT titration into several enterprise cardiology subspecialty clinics beyond a local heart failure clinic necessitated enhanced communication. Clear notification was needed from the provider to the appropriate nursing team to ensure patients were connected to the team who would enact the provider’s recommended plan of care and reduced delay in GDMT titration.

**Methods**
RNs are involved in heart failure medication titration across multiple care settings and clinics. There was a need to implement standardized quick reference guides, video demonstrations, and Electronic Health Record (EHR) resources. The addition of an EHR generated automated notification reduced confusion regarding which nursing group would manage a patient. Lastly, improved patient outcomes were achieved through multidisciplinary collaboration between nurses and providers.

**Results**
Automated notifications alerted nurses of a patient who required heart failure medication titration. This intervention improved nursing confidence in the program by 43%. A simultaneous EHR enhancement showed a 36% increase in provider order accuracy. Following these enhancements, numerous clinics initiated the use of the established heart failure medication titration provider entered orders and RN protocol. EHR enhancements allowed medication titration to be customized to meet individual patient needs. This intervention improved safety and reduced delays in care for patients requiring heart failure medication titration.
Pre-intervention, approximately 10% of patients were admitted to the hospital within 30 days of initiating the heart failure medication titration program. Post-intervention this rate decreased to 4%, decreasing hospital admissions within 30 days by more than half. Multidisciplinary improvements in the EHR resulted in an enrollment increase of 202% between 2021 and 2023. During the same period, the corresponding RN protocol experienced an increase in utilization of 132%.

**Conclusion**
Patients involved in RN-managed Heart Failure Medication Titration showed a 30-day readmission rate of approximately 12%. The national average of Heart Failure readmissions is 22.6% (Centers for Medicare [CMS] 2023). A well-designed EHR system was leveraged to facilitate enrollment in the RN-led GDMT medication titration program through automated notifications. Through this multidisciplinary approach to heart failure medication titration, we markedly reduced heart failure admissions within 30 days of enrollment. The introduction of autonotifications enhanced multidisciplinary collaboration and communication. This is a model which could be replicated in any other clinic where RN and prescriber collaboration occurs for patient follow up management.



Heart Failure Medication Titration in Ambulatory Care: Reducing gaps in care and preventing hospital admissions