A team from Medway PCT has designed a nurse-led heart failure – a successful initiative for which they received the overall Guidelines in Practice Award 2006
Heart failure represents a growing health problem. The past decade has seen significant advances in the treatment of heart failure; however, it still accounts for more than 5% of adult and geriatric hospital admissions. The duration of stay is frequently prolonged and in many cases is rapidly followed by readmission.1
The incidence and prevalence of heart failure is set to increase steadily over the next 25 years against the backdrop of an ageing population and improvements in medications to treat symptoms.2
The prognosis for heart failure is worse than for breast and prostate cancer.3
Annual mortality for those with heart failure ranges from 10% to over 50%, depending on the severity.4 Statistics suggest that 1–2% of the total population in the UK, and 10–20% of the elderly (aged over 70 years) have heart failure.5
Development of the service
In 2002, the coronary heart disease (CHD) local implementation team identified the diagnosis, treatment and management of heart failure as a priority in Medway and Swale.
The development of heart failure services across the area commenced in 2003, and was driven by the NSF for CHD,4 and subsequently by the NICE guideline on heart failure due to left ventricular systolic dysfunction.6
The heart failure service aims to modernize the provision for heart failure patients by:
- decreasing admissions
- providing equal access to care and treatment (including diagnostic testing)
- increasing local knowledge of heart failure for all healthcare professionals
- increasing quality of life for patients
- increasing quality of treatment
- providing support and care for end-stage heart failure patients
- facilitating services for heart failure patients, enabling them to receive a full package of care, social support, and palliative care applicable to their needs.
Service provision for heart failure has increased this year. The appointment of a heart failure nurse consultant has enabled the heart failure team to focus on and develop key services throughout the year (see Box 1).
|Box 1: Key areas of success of the community heart failure service|
|Box 2: Key objectives of the heart failure service|
Figure 1: Referral pathway into the Heart Failure Service
FBC: full blood count;TFT: thyroid function tests; U&E: urea and electrolytes; ECG: electrocardiogram; BNP: B-type natriuretic peptide; LFTs: liver function tests; ECHO: echocardiogram; LVSD: left ventricular systolic dysfunction
Referral to the service
Referral in to the heart failure service can be from either primary or secondary care once a diagnosis has been established. Within primary care, the service provides a pathway to establish the diagnosis of heart failure through relevant diagnostic testing (see below).
For patients referred from secondary care, consultant-led teams complete a referral and advise on action required (i.e. a management plan) so that there is continuity of care with minimal replication.
A cardiovascular liaison nurse, who is based in secondary care, relays referral information to the specialist nurses, reducing the time that the latter spends within the secondary care setting. This allows them to concentrate on patients within primary care.
'There is evidence to support the need of ensuring an adequate diagnosis as inadequate diagnostic testing leads to increased hospital readmission rates.'7
The B-type natriuretic peptide (BNP) blood test ensures that those patients needing echocardiography are correctly identified and referred for testing.8 Following extensive research by the project manager from the Kent Cardiac Network, a service to test BNP was launched in August 2005 and is available to primary care in Medway and Swale.
Echocardiograms are recognized as the gold standard for heart failure diagnosis.9 The heart failure echocardiogram service at Medway Maritime Hospital has been developed – effective administration was set up to allow timely access to echocardiograms following initial blood and ECG testing. Patients are invited for the scan within 3 weeks of referral to confirm or refute the diagnosis of heart failure. As many areas around the UK have a waiting list of over 12 weeks, this is a significant achievement.
Heart failure team
Interpretive guidelines, based on the NICE chronic heart failure guidance, have been written for both BNP testing and echocardiography, which are distributed to GPs along with test results.6 Practices also have access to locally produced guidelines to support their decision-making.
Once referrals are received and diagnostic testing is completed, the heart failure nurse consultant reviews the data and takes action accordingly.
Clinical support is provided by a consultant cardiologist on a weekly basis to review complex patients and validate diagnosis. At present, the heart failure team consists of:
- one nurse consultant
- four full-time specialist nurses
- two part-time specialist nurses
- one full-time administrator
- one part-time cardiovascular link nurse
- one part-time sports physiologist
- one part-time cardiac physiologist.
Over the past 2 years the team has moved, as originally planned, from a secondary care focus into primary care. Nurses now cover designated geographical areas and carry their own caseloads.
The benefit of specialist nurses
Specialist nurses make direct contact with patients on a regular basis. The telephone service provides emotional support to patients but is most effective for highlighting patients who are decompensating (i.e. those who experience deterioration in their symptoms). Treatment is then actioned to prevent hospital admission and improve the patient's condition. Patients and their families are offered home visits, clinic appointments or education sessions, depending on their needs at that point in time.
Links to palliative care
Links have been developed with colleagues who provide palliative care services.The heart failure team liaise with and facilitate appropriate referrals to the palliation service (with consent from the patient's GP). A monthly heart failure meeting is held with input from a doctor from the palliative care team.10 A liaison nurse ensures strong links are maintained between the two services. Heart failure patients are now able to access hospice day care facilities and admission to hospice beds.The heart failure nurses have undertaken specialist palliative care training, and one heart failure nurse is assigned to lead this project.
A patient education programme has been established. The programme provides advice, support, and education to patients and their carers. One heart failure nurse and the exercise physiologist lead the programme. It is hoped that when the new specialist nurses are fully trained, exercise programmes will also be available.
Education programmes for doctors have been developed as have various nurse education programmes, which have been run across both primary and secondary care settings. There has been full attendance at the sessions and feedback has been extremely positive.
One heart failure nurse has been allocated to ensure continuity of this education and training programme and to identify gaps in provision. A rolling education programme for various disciplines is underway – one survey of practice staff identified several learning needs in, for example, atrial fibrillation, arrhythmias, and ECG interpretation. A multidisciplinary programme will commence in April 2007.
Admission rates and length of hospital stay
Data from the Kent and Medway public health informatics department in 200511 identified that the age-standardized admission rate for heart failure for men in Medway was 114.69 per 100 000 and the age-standardized admission rate for heart failure for women in Medway was 67.35 per 100 000. Data for Swale shows the equivalent age-standardized figures for men as 111.16 per 100 000 and 62.80 per 100 000 for women.
When compared with the other Kent PCTs, Medway PCT ranked first with respect to admissions for heart failure for both males and females. The overall admission rates for heart failure were highest in Medway PCT, and Swale PCT came a close second. This data identified a local need – high admission rates were suggestive of poor early identification of heart failure patients and inadequate treatment.
Overall admission rates in Medway and Swale are comparable with previous years, with lengths of hospital stays down. This may be due to effective working across all areas including:
- community heart failure nurses in place to support early discharge
- prompt diagnosis with echocardiography
- 72-hour wards, i.e. short-stay wards.
Data collected by the heart failure specialist nurses show admission prevention for 20 patients in a 6-month period. With this year's average length of stay being 10 days, this equates to 200 bed days saved.
Inpatient discharge data
An audit of 52 discharged patients, to review inpatient data, showed that 24% were not identified as having had an echocardiogram (which is recognized as the gold standard for diagnosis of heart failure). Not all of the patients were discharged on an angiotensin-converting enzyme inhibitor and only 25% were discharged on a beta-blocker. If patients are not started on the appropriate medication, it can impact on their symptoms and survival.
The findings show that further work needs to be done in this area to ensure patients are receiving the correct management.
The data were presented to the elderly care and medical consultants at a meeting to highlight the problem areas and to encourage referral to the heart failure team who will then provide ongoing care.
QOF2 and the heart failure service
The GMS contract requires that all patients with heart failure are placed on a register and undergo echocardiography to confirm the diagnosis;12 this is also recommended by NICE.6
Recording of Read codes on practice computer systems has improved over the past year and the community heart failure team offers support to GP practices to progress this.
An audit was undertaken as a pilot project in line with the 3-year plan to assess the QOF data in general practices. Results highlighted that not all patients on the heart failure register were actively managed within primary care, and if managed, care was often provided by a specialist.This is an area where further work is currently underway.
With the expansion of the community heart failure service these points should be addressed, for example by providing education programmes and improving liaison, increasing local knowledge, and upskilling practitioners. There is already a project underway that supports 16 local practices with populating and validating their practice registers, thereby improving the quality of the treatment.
Management of patients suffering from heart failure is a key priority for Medway and Swale PCTs. Significant advances in diagnosis and treatment have been developed across the local health economy during the past year. Training programmes are now in place to provide education to health professionals, and work is well underway to develop the services further. Primary care providers have access to diagnostic testing to enable early diagnosis.
The QOF has enabled general practices to look at registers and identify patients with heart failure so that this group can be actively managed.
However, more work needs to be undertaken to ensure all patients receive a quality package of care and regular review.
This year has seen significant development and change for the heart failure service. There has been a major shift in provision of care to the primary care setting. Initial diagnosis is now possible via the community heart failure service, and a strong effective nurse-led team is now in place to provide care, treatment, and support in the community.
- Stewart S and Blue L (Eds). Improving Outcomes in Chronic Heart Failure: a Practical Guide to Specialist Nurse Intervention. Second edition. Oxford: Blackwell BMJ Books, 2004.
- Petersen, S, Rayner M and Wolstenholme J. Coronary heart disease statistics: heart failure supplement. London: British Heart Foundation, 2002.
- Hobbs R. Can heart failure be diagnosed in primary care? Br Med J 2000; 321 (7255): 188–189.
- Department of Health. National Service Framework for Coronary Heart Disease: Modern Standards and Service Models. London: DoH, 2000.
- Scottish Intercollegiate Guidelines Network (SIGN 35). Diagnosis and treatment of heart failure due to left ventricular systolic dysfunction. Edinburgh: SIGN, 1999.
- National Institute for Clinical Excellence. Chronic heart failure. Management of chronic heart failure in adults in primary and secondary care. Clinical Guideline 5. London: NICE, 2003.
- Stewart S and Blue L (Eds). Improving Outcomes in Chronic Heart Failure: a Practical Guide to Specialist Nurse Intervention. London: BMJ, 2001.
- Sim V, Hampton D, Phillips C et al. The use of brain natriuretic peptide as a screening test for left ventricular systolic dysfunction - costeffectiveness in relation to open access echocardiography. Fam Pract 2003; 20 (5): 570–574.
- Struthers A.The diagnosis of heart failure. Heart 2000; 84 (3): 334–338.
- Johnson M and Lehman R (Eds). Heart Failure and Palliative Care. Oxford: Radcliffe Publishing, 2000.
- Medway PCT Coronary Heart Disease, Health Equity Audit 2005.Kent: Medway PCT, 2005.
- British Medical Association. Revisions to the GMS contract 2006/2007: Delivering Investment in General Practice. London: BMA, 2006.