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 Table of Contents  
Year : 2019  |  Volume : 5  |  Issue : 1  |  Page : 2-11

Checklists – The road to a safer healthcare in heart failure patients

Departments of Cardiology, AIIMS, New Delhi, India

Date of Web Publication2-May-2019

Correspondence Address:
Dr. Sandeep Seth
Department of Cardiology, AIIMS, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpcs.jpcs_23_19

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Health care today is complex and mistakes can occur due to multiple reasons from lack of knowledge to simply lack of attention to detail. Checklists are a way to prevent mistakes and implement common standards of care but there are difficulties in implementing checklists. In this article we are showing a series of checklists which we have successfully used in the management of heart failure in a tertiary care hospital in India. The checklists start from the time the patient is admitted (the Intensive care Check list) to the time of discharge. The patient's visit to the out patient department is also covered by multiple education cards and checklists (Heart Failure Checklist, HRIDAY CARD). There are also standard prognostic tools (Seattle heart failure score and many others) which are used to prognosticate patients which do not respond to drug therapy. The I-NEED-HELP tool is explained to choose patients who might benefit from an cardiac assist device or a heart transplant.

Keywords: Checklist, decompensated heart failure, guideline-directed medical therapy

How to cite this article:
Kidambi BR, Seth S. Checklists – The road to a safer healthcare in heart failure patients. J Pract Cardiovasc Sci 2019;5:2-11

How to cite this URL:
Kidambi BR, Seth S. Checklists – The road to a safer healthcare in heart failure patients. J Pract Cardiovasc Sci [serial online] 2019 [cited 2023 Jun 10];5:2-11. Available from: https://www.j-pcs.org/text.asp?2019/5/1/2/257599

“To Err is human, to remain in error is diabolical”

-Georges Canguilhem.

  Introduction Top

Since times immemorial, healthcare has always been a highly complex field to fathom. The mercurial rise in last few decades has led to increasing experts (super specialty) in various fields within healthcare. Along with the advancements comes the moral responsibility of every doctor to uphold the safety of the patients. Cardiology has always been a highly complex field with growing complexity each day. The mortality rate of various cardiovascular diseases despite the advancements in technology and newer drugs remains high. When compared with other high risk, high complexity jobs involving people's lives (e.g., Aviation and Skyscraper), healthcare has an unreasonably excessive mortality. While analyzing this, Dr. Atul Gawande, in his beautiful book – “The Checklist manifesto”[1] discovered that those industries use a Checklist as a tool to reduce the avoidable errors. Checklists are a tool to make experts better. In this article, we will talk about the importance of checklists, and its usage in heart failure (HF) patients and other cardiac diseases in our institution.

  Heart Failure in India – the Never Ending Problem Top

HF burden in India is underestimated due to an inadequate surveillance system. The available data are shown in [Table 1].[2],[3]
Table 1: Indian data on heart failure

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The typical HF patients in India are different in the following ways:

  1. Younger age of onset of HF (at least 10 years younger) – The mean age in the THFR, Medanta Registry, and the INTER-CHF (Indian subset) study was 61.2, 58.9, and 56 years, respectively, as compared to 72.4 years in the ADHERE Registry of the USA
  2. RHD is an important etiology
  3. Male: female ratio is 70:30, compared to 50:50 in west. The effect of the prescribed drugs and the maximal tolerated doses among women are underreported
  4. Prognosis is worse. Postadmission mortality is around 20%–30%. Many people in India have to pay out their pocket unlike the western counterparts
  5. Prevalence of HF with diabetes is more.

There has been increasing use of devices for the treatment of HF – CRT, ICD, ECMO, left ventricular assist device, and heart transplant. Prior optimization of the drug regimen is very essential for a successful outcome.

We can see that a substantial number of patients at discharge are not getting adequate guideline-directed medical therapy mostly because of concern for adverse drug events.

The complexity of the treatment regimens and the available data on them are so enormous for a single person to efficiently apply on day-to-day patients without errors. There has been a recent appraisal for using checklist as a tool to reduce avoidable error rates and to be better prepared in cases of unexpected catastrophes.

  Check List – the Tool to Make Expert's Better Top

”Know-how and sophistication have increased remarkably across almost all our realms of endeavour, and as a result so has our struggle to deliver on them…. Avoidable failures are common and persistent, not to mention demoralizing and frustrating, across many fields—from medicine to finance, business to government. And the reason is increasingly evident: the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably. Knowledge has both saved us and burdened us” - Gawande (The Checklist manifesto-2010).

The concept of a checklist being used as a memory aid is not new. During the medieval times, all architecture used to be built under the guidance and planning of a master builder. Subsequent decades saw increasingly complex architectural wonders, which could not be handled by a single master builder. Then came the concept of using a checklist as a memory tool to reduce the “human errors” which were essentially due to flaws in memory.

High reliability organizations (HROs) are organizations which perform highly hazardous operations with exceptionally low failure rates. Healthcare over time has become from simple, efficient, and safe to complex, inefficient, and hazardous. Checklist was the primary tool of HRO in reducing the failure rates of their organization.

Aviation industry was the first of the HRO which successfully implemented use of checklists after the crash of Boeing 299 in 1935 due to a simple “human” error. The list of HRO which are using checklist as a tool is described in [Table 2].
Table 2: Checklists in various organizations

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  Checklist in Healthcare Top

The first landmark use of checklists was the WHO Surgical Safety Checklist which was approved in 2008.[4] Following that, there has been multiple attempts at using checklist for various specialties.

The characteristics of a good checklist are:

  1. Small checklist (longer checklist tend to be more cumbersome and would defeat the purpose)
  2. Time duration to complete the checklist – shorter the duration, the better chances of it being implemented
  3. Appropriate use of font and boldface, color to enhance the importance of the highlighted points
  4. Regular change, validation of the checklist according to institution experience and changing guidelines.

In HF, the concept of a checklist was tested by Basoor et al.[5] The authors developed and evaluated a quality improvement HF checklist to remind physicians to improve quality of care in HF patients. The checklist was used in patients admitted with decompensated HF. It included medications and dose up titration, counseling, and follow-up instructions at discharge. The checklist was used in 48 patients and 48 controls. Higher proportions of patients were taking angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) in the checklist group compared with the control group (40 of 48 vs. 23 of 48). The rate of dose up titration for β-blockers and/or ACE inhibitors/ARBs was more common in the checklist group. 30-day (19% to 6%) and 6-month (42% to 23%) readmissions were lower in the checklist group. The use of an HF checklist was associated with better quality of care and decreased readmission rates for patients admitted with HF.

The AIIMS HF Checklist was created based on the mistakes made at various stages of management of acute HF and the transitions from acute to chronic HF. Similar checklists were created for the management of heart transplant patients. Each checklist and its justification is discussed. These checklists are available for use. They can be downloaded from the article or separately requested from the authors.

These checklists cover the pathway from the hospital admission to discharge and then the OPD visit. When a patient is admitted, appropriate management [6] [Table 3] includes appropriate use of diuretics, inotropes, vasodilators, transition to ACE inhibitors or ARB or ARNi along with beta-blockers and ivabradine and appropriate supportive care and discharge planning to the next OPD visit. This is summarized in [Table 3], [Table 4] and [Figure 1] (the HF checklist used at AIIMS at admission in the ICU).
Table 3: Acute heart failure: treatment and investigations

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Table 4: AIIMS heart failure critical care unit Checklist

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Figure 1: ABCD checklist.

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[Figure 1] shows the steps involved in the management of acute HF.

The checklist in [Table 4] is used to implement the above guidelines for the management of acute HF.

[Table 4] is the AIIMS HF CCU checklist. It is self-explanatory, and the objective is to ensure the appropriate doses of diuretics are started when the patient is admitted, the switch to oral from intravenous drugs is at a high dose, inotropes are started only when indicated. The use of vasodilators should start appropriately as should beta blockers. The newer drugs angiotensin receptor blocker-neprilysin inhibitors have been shown to improve outcomes in acute HF beyond standard ACE inhibitors and should be considered wherever possible to improve acute HF outcomes. Adding ivabradine to beta blockers should also be considered since they have also been shown to reduce hospital readmissions and cardiovascular mortality. The other points covered in the checklist include ensuring vaccination, appropriate management of comorbidities such as coronary artery disease and diabetes, anticoagulation, and vaccination. It also covers fixing an appointment at day 7 after discharge since most complications after discharge occur in the 1st week and first month, and this period should have weekly and then fortnightly OPD visits to pick up and prevent complications. Once the patient is discharged from the hospital, data show that only about three-fourth of the patients get vasodilators and half get beta blockers.

We looked at our own data from the AFAR study [Table 5]. At discharge, 47% patients were on beta blockers and 71% were on either a ACE inhibitor or ARB. With this, the 6-month readmission/mortality rate was 39.5%. Clearly, efforts can be done to increase the usage of beta blockers and ACE inhibitors' predischarge in these patients. In a pilot study, an MSc student nurse ran a training program for nurses and implemented a HF checklist-based study. This leads to an improvement in the usage of guidelines-based medications in the patients admitted with HF [Table 6].
Table 5: Acute failure registry study

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Table 6: Comparison of patient outcomes before and after implementation of heart failure clinical pathway

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As [Table 6] shows, educating nurses in the management of HF using a HF checklist leads to an increase in the use of beta blockers, a slight increase in the use of vasodilators, and increased vaccination rates. This translated into a trend toward reduction of readmission rates and mortality at 1-month follow-up.

Once the patient is discharged, the risk of readmission and mortality is very high in the next 3 months, and therefore, every effort should be made to put the patient on guideline-based therapy in the next 3 months, anticipate any complications and keep the patient on very close follow-up and also advise the patient on any device therapy if the patient qualifies (CRT or left ventricular [LV] assist device), and if the patient is worsening in spite of everything, then consider for a heart transplant or LV assist device.

When the patient visits the OPD for the first time after a HF admission, we implement a checklist-based plan in the HF Clinic. [Table 7] represents an OPD checklist which is filled by the HF nurse or the dietician or the research fellow or any volunteer. A stamp is also put on the OPD card with A B C D written, with A referring to ACE inhibitors or any other vasodilator, B meaning the beta blockers and/or ivabradine, C are the companion drugs where all the extra drugs are added, and D refers to the diuretics [Figure 2].
Table 7: Heart failure clinic: Checklist filled by heart failure nurse: The ABCD check list

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Figure 2: OPD card stamped.

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We also use a HF passport (Hriday Card)[10] in these patients. A One Page Heart Failure Passport (Hriday Card) is reproduced here, and this can easily be printed and used.

Detailed and full copies can be obtained from the authors. Color Print of [Figure 3] can be used to initiate a heart failure clinic service and the back side can be used to write the prescription. The full copy of the Hriday Card [Figure 4] with medication charts and weight records can be obtained from the authors on request. Panel A is the front of the card which contains the details of the patients, also a blank space where we can enter a helpline number and hospital stamp or details. Panel B is the HF OPD checklist in brief which is filled by the healthcare workers or nurses. Panels C and D are the medicine and weight card which are kept inside the Hriday Card in pockets. Panel E teaches the patient how to respond to common problems in heart failure. Panel F explains the usual precautions with HF in a pictorial depiction.
Figure 3: Hriday single page copy (can be printed and used). This is a shortened version of the Hriday Card which can be directly printed and used. The front side on the right (b) contains the patient's name and other details and very brief instructions about heart failure (daily weights, no drinking and smoking and salt and water restrictions). The panel on the left (a) is a brief checklist which covers essentials for heart failure management which are missed including starting angiotensin-converting enzyme inhibitors or beta blockers, or anticoagulants, statins, vaccination, etc.

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Figure 4: Full Hriday card. Sections a to f are different sections of the Hriday Card and are explained in the text. (a) Front (b) Checklist (c) medicine log (d) weight log (e) response card (f) education chart.

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Sick patients also need to be risk stratified.[11] There are various ways to do that.

One method is the “I NEED HELP” method [Table 8]. This is self-explanatory. Patients who fulfill these criteria are more in need of advanced therapy like a heart transplant or an LV assist device and might not be manageable by drug therapy alone.
Table 8: I need help

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Scores have also been used.

The Seattle, Shift, and MAGGIC scores [12],[13],[14],[15] have been used to predict risk of events in patients with HF [Figure 5], [Figure 6], [Figure 7]. The Seattle score is an older and more widely used score, and the MAGGIC score is a recent score. Most of these scores are better able to prognosticate sicker patients but are unable to predict events as accurately in less sick patients. The Shift calculator is another calculator which is simple to use.
Figure 5: Seattle heart failure score.

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Figure 6: The MAGGIC score.

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Figure 7: The SHIFT calculator.

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[Table 9] gives similar suggestions for the management of hypertension, diabetes, and ischemic heart disease. In ischemic heart disease, A covers aspirin and other antiplatelets, B refers to beta blockers and other antianginals, C covers preventive measures including cholesterol lowering and smoking cessation, D includes treatment of risk factors such as diabetes and hypertension, and E includes exercise and education. In hypertension, A includes Ace inhibition or ARBs, especially for the young, B includes beta blockers in combination, C includes calcium channel blockers, especially in the older, and D includes the diuretics again often in combination. In diabetes, A includes use of ACE inhibitors and aspirin, B includes blood pressure control, C is cholesterol control, and D is the diabetes control.
Table 9: Check lists for Cardiovascular Diseases

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Most of the above checklists have been tested in our clinics and are available at our HF website: https://jpcsindia4.wixsite.com/crc2 and have been found to be effective in improving long-term outcomes in terms of morbidity and mortality.[16],[17],[18]

  Conclusions Top

It has been proven time and again that checklists can improve patient care, improve medication compliance, reduce hospital readmissions, save medical care costs, prevent human errors, and standardize medical care.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Gawande A. Checklist Manifesto, the (HB). Penguin Random House Gurgaon, India, 2017 Edition.  Back to cited text no. 1
Mishra S, Mohan JC, Nair T, Chopra VK, Harikrishnan S, Guha S, et al. Management protocols for chronic heart failure in India. Indian Heart J 2018;70:105-27.  Back to cited text no. 2
Seth S, Khanal S, Ramakrishnan S, Gupta N, Bahl VK. Epidemiology of acute decompensated heart failure in India: The AFAR study (Acute failure registry study). J Pract Cardiovasc Sci 2015;1:35.  Back to cited text no. 3
Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491-9.  Back to cited text no. 4
Basoor A, Doshi NC, Cotant JF, Saleh T, Todorov M, Choksi N, et al. Decreased readmissions and improved quality of care with the use of an inexpensive checklist in heart failure. Congest Heart Fail 2013;19:200-6.  Back to cited text no. 5
Čerlinskaitė K, Javanainen T, Cinotti R, Mebazaa A; Global Research on Acute Conditions Team (GREAT) Network. Acute heart failure management. Korean Circ J 2018;48:463-80.  Back to cited text no. 6
McMurray JJ, Packer M, Desai AS, Gong J, Lefkowitz M, Rizkala AR, et al. Baseline characteristics and treatment of patients in prospective comparison of ARNI with ACEI to determine impact on global mortality and morbidity in heart failure trial (PARADIGM-HF). Eur J Heart Fail 2014;16:817-25.  Back to cited text no. 7
Pascual-Figal D, Wachter R, Senni M, Belohlavek J, Noè A, Carr D, et al. Rationale and design of TRANSITION: A randomized trial of pre-discharge vs. post-discharge initiation of sacubitril/valsartan. ESC Heart Fail 2018;5:327-36.  Back to cited text no. 8
Velazquez EJ, Morrow DA, DeVore AD, Ambrosy AP, Duffy CI, McCague K, et al. Rationale and design of the comParIson of sacubitril/valsartaN versus enalapril on effect on nt-pRo-bnp in patients stabilized from an acute heart failure episode (PIONEER-HF) trial. Am Heart J 2018;198:145-51.  Back to cited text no. 9
Seth S, Vashista S. The hriday card: A checklist for heart failure. J Pract Cardiovasc Sci 2017;3:5.  Back to cited text no. 10
  [Full text]  
Baumwol J. “I need help”-A mnemonic to aid timely referral in advanced heart failure. J Heart Lung Transplant 2017;36:593-4.  Back to cited text no. 11
Yancy CW, Januzzi JL Jr., Allen LA, Butler J, Davis LL, Fonarow GC, et al. 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment: Answers to 10 pivotal issues about heart failure with reduced ejection fraction: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. J Am Coll Cardiol 2018;71:201-30.  Back to cited text no. 12
Levy WC, Mozaffarian D, Linker DT, Sutradhar SC, Anker SD, Cropp AB, et al. The seattle heart failure model: Prediction of survival in heart failure. Circulation 2006;113:1424-33.  Back to cited text no. 13
Sartipy U, Dahlström U, Edner M, Lund LH. Predicting survival in heart failure: Validation of the MAGGIC heart failure risk score in 51,043 patients from the Swedish heart failure registry. Eur J Heart Fail 2014;16:173-9.  Back to cited text no. 14
Ford I, Robertson M, Komajda M, Böhm M, Borer JS, Tavazzi L, et al. Top ten risk factors for morbidity and mortality in patients with chronic systolic heart failure and elevated heart rate: The SHIFT risk model. Int J Cardiol 2015;184:163-9.  Back to cited text no. 15
Chaturvedi V, Parakh N, Seth S, Bhargava B, Ramakrishnan S, Roy A, et al. Heart failure in India: The INDUS (INDia ukieri study) study. J Pract Cardiovasc Sci 2016;2:28-35.  Back to cited text no. 16
  [Full text]  
Seth S, Ramakrishnan S, Parekh N, Karthikeyan G, Singh S, Sharma G. Heart failure guidelines for India: Update 2017. J Pract Cardiovasc Sci 2017;3:133.  Back to cited text no. 17
  [Full text]  
Rai M, Sharma KK, Seth S, Pathak P. A randomized controlled trial to assess effectiveness of a nurse-led home-based heart failure management program. J Pract Cardiovas Sci 2017;3:28.  Back to cited text no. 18


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]

This article has been cited by
1 Consensus And Development Of Document For Management Of Stabilized Acute Decompensated Heart Failure With Reduced Ejection Fraction In India
U. Kaul,M.K. Das,R. Agarwal,H. Bali,R. Bingi,S. Chandra,V.K. Chopra,J. Dalal,U. Jadhav,P. Jariwala,A. Jena,R. Gupta,P. Kerkar,S. Guha,D. Kumar,M. Mashru,A. Mehta,J.C. Mohan,T. Nair,D. Prabhakar,R. Ray,R. Rajani,S. Sathe,N. Sinha,G. Vijayaraghavan
Indian Heart Journal. 2020;
[Pubmed] | [DOI]


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