the challenges and opportunities of improving heart failure management in the community
TRANSCRIPT
The Challenges and Opportunities of Improving Heart Failure Management
in the Community.
McIntyre et al (2002) “Heart failure care is fragmented
due to a lack of understanding between primary and secondary care.”
Guidelines“Rome wasn’t built in a day”
1997 ‘The New NHS’ 1998 ‘Saving Lives’ 2000 NSF for CHD 2011 NICE for CHF 2004 GMS Contract 2007 SIGN Updated
Guidelines
Primary & Secondary Care
3 Recent Impacts
Movement of services out of secondary care
GMS contract for GP’s Introduction of the role of Community
Matrons
Nicholson C, 2007
Movement of services out of secondary care
Hospital services congested, patient experience often poor, diagnostics, treatment and follow-up can be done in primary care.
Nicholson C, 2007
CHF management is likely to be shared between primary and secondary care
NICE 2003
CHF mortality and readmission is reduced by home/clinic-based specialist teams
SIGN 2007
GP Contract for General Medical Services (GMS)
GMS Contract – 2004 Payment by results, Quality and
Outcomes Framework (QOF) 3 Heart failure point indicators-LVSD1 = Register-LVSD2 = Diagnosis confirmed by
echo.-LVSD3 = ACE Inhibitors prescribed
Nicholson C, 2007
Health Care Commission Effective diagnosis Evidence based treatment and
monitoring MDT approach with educational
support Are services having positive effect Scored weak/fair/good/excellent
Heart Failure Service Commenced April 2009 Team = HFNS 22.5 hrs x 2 GPwSI Dr Andy Gallagher Secretary 15 hrs Referral Criteria = LVSD Evidence Catchment area=Lancaster,Garstang,
Morecambe & Carnforth (Ash Trees) only
Fax referral, from primary or secondary care, by all staff
What is Heart Failure?
“Heart failure is a complex syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the heart to function as a pump to support the physiological circulation”, NICE (2003).
How Big is the Problem? Around 900,000 people in the UK today
have heart failure. Increases steeply with age. 40% of heart failure patients die within
a year but thereafter mortality is less than 10% per year.
A GP will look after 30 patients with heart failure and suspect a new diagnosis of heart failure in perhaps 10 patients annually.
£45 million per year with an additional
£35 million for GP referrals to outpatient speciality
Drug therapy costs the NHS around £129 million per year.
Heart failure accounts for 2% of all NHS bed days and 5% of emergency admissions to hospital.
Projected to rise by 50% over the next 25 years, (Gnani & Ellis, 2001).
Heart failure costs the NHS £716 million
per year. Readmission rates are as high as 50% in
the elderly six months following discharge.
(NICE, 2003)
So Why Is Heart Failure So Important? Extremely Debilitating Worse prognosis than most
cancers Unpredictable terminal trajectory Accounts for 4% of all deaths Largest single reason for bed days
due to chronic condition
Chronic Heart Failure (CHF)
CHF is a debilitating long-term illness and exerts a heavy burden upon both the individual and society.
Stewart S & Blue L 2001
Prevalence is expected to continue to rise over next several decades due to decreased mortality from cardiovascular disease and the growth of the elderly population
ESC 2001
The NSF CHD
Standard 11 (Heart Failure)
Help patients to live longer and achieve a better quality of life.
Help patients with unresponsive heart failure to receive appropriate palliative care support.
Causes of Heart Failure Ischeamic Heart Disease Myocardial Infarction Uncontrolled hypertension Valvular
disease(particularly Aortic & Mitral Valves)
Cardiac Arrhythmias Myocarditis Toxic substances –
Alcohol/Medications/Viral Anaemia Hyperthyroidism Pregnancy Congenital Heart Disorders
Signs Pulmonary Crepitations Pleural Effusion Oedema, Ascites Raised JVP Valve SoundsSymptoms Fatigue SOBOE Orthopnoea Acute SOB Loss of appetite Weight gain
The 3 Elements of HF The initial injury Impairment in function Abnormal circulatory response
Cardio-Renal model
Impaired ability of the heart to contract
Impaired supply to the kidneys
Sodium and water retention
Peripheral oedema-Heart Failure
Neurohormonal Model The basis for all heart failure treatment
today Heart Failure develops and progresses
because of NS Activated by the initial injury to the
heart Exerts deleterious effects on the heart
and circulation, independent of the haemodynamic status of the patient
The cardiac neuroendocrine effect RAAS Adrenergic activation ADH Endothelins Natriuretic peptides
How the heart reacts The BP increases The size of the heart increases The heart becomes stiff and rigid The pulse rate increases Cardiac output falls Hypertrophy Atherogenesis Vessel Wall Fibrosis
But What happens when there is too
much fluid in the body BNP
Systolic or Diastolic HF 60% of Patients thought to have LVSD 40% Diastolic No clinical trials completed for diastolic
so management very much diuretic therapy due to potential for fluid retention.
More likely to be admitted to hospital LVSD-Proven clinical trials base
treatment with clear outomes Charm, CIBIS, AIRE, Rales
Treatment Options Diuretics (Symptom Control) Inotropes (Rarely Used) Vasodilators (Symptom Control) Betablockers (Improve Outcomes) ACE therapy (Improve Outcomes) Spironolactone (Improves Outcomes) Digoxin
Basic Management Take medications Restrict oral fluids 1.5 – 2 litres daily Salt-free diet Weigh daily Exercise, non-smoking, alcohol
limits, healthy diet, weight management, etc.
Cardiac Resynchronisation Therapy (CRT) & Internal Cardiac
Defibrillators (ICD)
Widespread use NICE 2003
guidelines ICD management
in palliative care.
Achieving Cardiac Resynchronization
Goal: Atrial synchronous biventricular pacing
Doug Smith:Doug Smith:
Right AtrialLead
Right VentricularLead
Left VentricularLead
ICD Shock delivered in
pulseless Ventricular Tachycardia (VT) or Ventricular Fibrillation (VF)
Cardiac arrest not to be confused with heart attack.
New York Heart Association Classification
of Heart Failure
Class 1–No limitation during ordinary activity
Class 2–Slight limitation during ordinary activity
Class 3–Marked limitation of normal activities
without symptoms at restClass 4–Unable to undertake physical
activity without symptoms. Symptoms at rest.
The Criteria Committee of the New York Heart Association 1973, Stewart & Blue 2004
Heart Failure Service Aims Optimal medical therapy Prevent rehospitalisation Increase functional ability Improve quality of life Improved healthcare outcomes Reduce mortality rates Reduce outpatient referral Improve patient education Treat unstable patients
Bosson O, 2004
Local Strategies Patient focused in order to empower an
active patient role. Improved liaison between primary and
secondary care to provide a seamless service.
Access to diagnostic services. Help to identify inpatients who may benefit
from the service. Improved aftercare to prevent readmission.
Need to be underpinned By The ability to identify as many patients as
possible who could benefit from the service. Confirmed diagnosis. Managed within an area convenient to
them. Motivation to review them regularly“Ultimately the more the patient understands
their condition the better their quality of life”, (BHF, 2007).
The Role of the Heart Failure Nurse Care and advice to patients across a
variety of settings. Decrease hospital admission and
readmission rates. Improve quality of life. Monitor patients conditions, readjusting
their medication when appropriate. Advise on lifestyle changes. Provide emotional support.
Work in collaboration with MDT colleagues. Provide education to colleagues. Ensure service is audited effectively. Help to develop heart failure register. Utilise guidelines to help guide care. Input from local hospice for heart failure
patients. Educate patients Direct contact for advice
So how do we go about this?
See patients in both primary and
secondary care settings. Provide support in the commencement of
medication as well as self management. Follow up home visits. Telephone contact. Regular review within clinics. Liase with MDT colleagues. IT
Palliative Care Continue medications that assist cardiac
function for as long as possible ACE/ARB II. eg Ramipril, Beta-blockers eg Bisoprolol, Diuretics eg Furosemide, Aldosterone-antagonist eg Spironolactone Diuretic therapy IV should be considered Morphine
The typical Heart Failure Trajectory
Palliative Care Cont.
All palliative care but Continue diet and fluid restrictions Observe weight recordings Consider ICD device
From Exercise……… Previously HF used
to considered an absolute contra-indication to participation in exercise prescription
Encourage regular aerobic and/or resistive exercise – may be most effective when part of exercise programme.
NICE 2003
Evidence of reduced mortality ExTraMATCH 2004
_
…..to Palliative care.
“Suddenly aborting heart failure services and transferring to palliative care is neither sensible nor preferable. Patients benefit from the support of both, based on individual needs and choices.”
Nicholson C, 2007
Opportunites
To make a real difference To develop a robust service for the
future To promote CHF management as a
community speciality
Referral Criteria Take referrals from medical staff,
ward areas, GPs and community staff.
North Lancashire Teaching Primary Care Trust
HEART FAILURE SERVICE
Please refer North Lancashire Teaching Primary Care Trust patients with SYMPTOMATIC left ventricular dysfunction or Diastolic Heart Failure for follow up by the heart failure service. We endeavour to carry out
the initial contact assessment within 7 days.
Heart Failure Service TeamRob Sharkey Heart Failure Specialist Nurse
Sue Leveridge Heart Failure Specialist NurseDr Andrew Gallagher GPwSI
Please fax referrals to 01524-61443
Contact details Tel 01524-61443Rosebank Medical Practice, Ashton Road, Lancaster LA1 4JS
[email protected]@northlancs.nhs.uk
This is an NLPCT service and we accept referrals from practices in Lancaster, Morecambe, Carnforth (Ash Trees), and Garstang (Windsor Road and Landscape Surgeries)
Started with this
We might not make this
Development of a local service,
taking into account local needs and wishes.
We don’t have all the answers, are not the experts, but seek to deliver quality of care to patients to improve quality of life and life expectancy.
Case Study 72 yr old female with breathlessness, fatigue leg oedema.Diagnosed
with Aortic stenosis and had TAVI 6 month previous. Chair bound due to breathless state and fluid. Exercise capacity 5 yards. NYHA 4
Ref made as palliative care from consultant and GP Ramipril 1.25mg/Bisoprolol 1.25mg/Frusemide 40mg. 1st visit-increased Ramipril to 2.5mg, changed to Bumetanide 3mg,
started nutritional drinks. HF Education. 2nd visit-Ramipril increased 5mg, added ISMO 10mg BD & Oramorph
2.5mls prn, LTOT. 3rd visit-Bisoprolol increased 2.5mg, added Spironolactone 25mg. 4th visit-Ramipril to 10mg Weight loss of 16lbs, EC 100 yrds, No fluid excess. Bumetanide 1mg,
O2 not required. Feels back to pre illness state, weight gain naturally. NYHA 2/3 Renal function stable. Follow up 3 monthly
The End
Any Questions?