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

robert.sharkey@northlancs.nhs.uksusan.leveridge@northlancs.nhs.uk

andrew.gallagher@gp-p81056.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?