Sandwell Community Heart Failure Team. Community Heart failure Specialist Nurses: Hilda O Keeffe- Henry and Jacqui Elson-Whittaker

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1 Sandwell Community Heart Failure Team Community Heart failure Specialist Nurses: Hilda O Keeffe- Henry and Jacqui Elson-Whittaker

2 NICE 2010 Incidence and Prevalence 900,000 people in the UK with HF Same amount with damaged hearts yet to develop the clinical syndrome 1 in 35 aged / 1 in 15 aged / 1 in 7 aged 85 + HF LVSD improved survival IHD & effective treatment HF HFPEF due to increase in survival HTN DM AF obesity Risk HF higher in men more women in the elder population

3 Community Heart failure Team Cover Six Localities of Sandwell Oldbury /Smethwick Rowley Regis/Tipton Wednesbury/West Bromwich Also Great Barr/Kingstanding/ Walsall

4 What is the Community Heart Failure Service? It is a follow up service for patients who have been diagnosed with Left sided/right sided Heart Failure and Heart failure Syndrome. The Team consist of: Three Specialist Heart failure Nurses Three heart Failure Nurses One Health Care Assistant One P/T Administrator.

5 WHAT DOES THE SERVICE PROVIDE? Specialist nursing for the management, support and education of patients with chronic heart failure. We offer a holistic approach to patient care.

6 Medication management /commencement/titration Clinical assessment/ home or community clinic Psychological support for both patients & carers Monthly life style support group meeting Blood test/ Electrocardiograms Identify any further support patients require.

7 Collaborative Approach We work closely with other professionals to improve the outcomes for patients and reduce hospital stays. Cardiologists Specialist Heart failure Nurses in Secondary Care GPs ICARES Other members of the multi disciplinary teams, i.e. respiratory, District Nursing, diabetes, equipment store

8 Who can refer to Heart failure Service Secondary Care Consultants GPs Nursing Staff Patients self referral We accept referrals from all sources as long as the person has a confirmed diagnosis of heart failure. (see referral form)

9 Team Audit Team use NICE CHF guidance CG108 (2010) (Updated 2012 to include Ivabradine (TA267)) Pathways include map of medicine and NICE

10 NICE Guidelines No stipulation of specific time frame for completion of titration The recommendation is to start at low doses Recognises that some patients tolerance of drugs is lower More frequent monitoring in older patients Management of heart failure should be determined by clinical criteria, irrespective of the age of the person

11 Team audit data collection 6 mths 109 New Referrals 7 Redirected to Cardiac Rehab 52 excluded not meeting criteria 9 patients re-admitted prior to titration being commenced 41 included in audit

12 Audit Findings Majority of patients referred via hospital Patients routinely followed up within 7 days (sometimes earlier) Titration only commences if patient s condition allows Delay in Beta-blocker titration in patients who are fluid overloaded, hypotensive or who are bradycardic Aim is to titrate to Target dose/optimum dose tolerated by patient.

13 Diagram 7.

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15 Diagram 5

16 Audit concluded Clinicians titrating drugs within clinical guidelines Safe titration can be very time consuming, involving numerous contacts with patient Time frame can be over a long period, stop/start/up/down Very few patients can tolerate target dose of drugs

17 GP questionnaire Methodology - Prospective Time allowed for return of forms- 1 month Date Sample size- 58 GP surgeries within the Sandwell area Returned forms= 35

18 Indicators Where is surgery based? Is the HF service beneficial to the practice? Has the availability changed referral habits? What are benefits of service? Suggested improvements?

19 Response to question: is the heart failure service beneficial to your practice? 3 Beneficial Neutral No 32

20 Has the community HF service changed GP referral habits? 3, 9% 19, 54% 13, 37% Neutral No Yes

21 SUMMARY of responses benefits of service Close monitoring of patients Good communication Good support for GP and patient Hospital avoidance through alterations in treatment Monitoring and early review Ensure compliance with NICE standards

22 SUMMARY of response- suggested improvements Continue the service and collaborate with GPs Request to join practice meeting to discuss patients Access to echos Improve palliative service.

23 CASE STUDIES Year old Afro Caribbean Man attended A&E complaining of increasing shortness of breath over a number of weeks, exercise tolerance limited due to dyspnoea. Patient was given an X-ray sent home on antibiotics and salbutamol inhaler- diagnosed with chest infection - a few days later patient received a letter to inform him that the X-ray had shown a slightly enlarged heart and congestion on the lungs, the letter informed him his GP may want to refer him on. 4 months later the patient reported he could not lie down in bed, could not climb stairs and his legs were very swollen. His GP sent him to Russells Hall Hospital who admitted him. He was Hypertensive BP on admission to hospital 152/122

24 Following an echo he was diagnosed with: Severely impaired left ventricle systolic dysfunction EF 10% Dilated right heart with globally severely impaired right ventricle Moderate MR & TR significant PHTN Echo suggested dilated cardiomyopathy The aetiology of his heart failure has not been identified as he has not any other investigations to date.

25 Patient s treatment to date Discharged from hospital on 20/9/13: Aspirin 75mg od Furosemide 40mg bd Hydralazine 50mg TDS Perindopril 2mg od GTN Spray - no confirmation of IHD Referred to Heart Failure Service

26 Seen In Community Heart Failure Clinic 03/10/13 BP 130/120 Heart Rate 95 reg Patient complaining of discomfort in centre of chest discomfort in left shoulder using GTN spray with good effect. No peripheral oedema chest appears clear on auscultation. Exercise tolerance limited to 400yds on the flat, short of breath on inclines and stairs Sleeping with 3 pillows PND at least twice a week. What would you do with this patient?

27 Review Patient lost prescription- too scared to tell Hilda B/P 150/120 HR 103 regular No oedema Admitted stopped Hydralazine- unwell, head felt terrible.

28 What did Hilda do? Not tell him off relationship building TRUST (he d made her a banana cake) Re prescribed Bisoprolol 2.5mg od Increased Perindopril 8mg od (discussed with cardiology dept.) Rebooked 1 week Contact numbers heart failure team Younger patients have different agenda s? Clear understanding of HF diagnosis eg different if told he had cancer/ avoidance/ denial

29 Case Study year old white British male PMH- HTN, Reflux oesophagitis Golf course manager (active) Flu like symptoms commenced Autumn 2012 with residual fatigue, dyspnoea on exertion, chest tightness. Obese- wt initially 173kg (no alcohol/non smoker) Lives with wife and 3 young children

30 Saw GP, treated for chest infection- advised to.. Lose weight Persistent dyspnoea lying flat, fatigue.. Referred to Consultant Cardiologist January 2012

31 Assessment February 2013 ECG- Atrial Fibrillation bpm Echo- Poor subject- LVH with globally severe systolic dysfunction. Dilated atria. Advice from Cardiologist Start Warfarin Lose weight Suggest to start ACE I

32 Follow up August 2013 Assessment by different cardiologist - Only Taking Warfarin, Lansoprazole - Recent treatment for chest infection and cellulitis - Weight loss 24kg NYHA I - Atrial fibrillation- poorly controlled 120 QRS 120ms - B/P 132/104, Heart sounds normal, chest clear, trace peripheral oedema

33 What did Cardiologist do? Start Perindopril 4mg od Start Bisoprolol 1.25mg od Arrange MPI scan? Underlying CAD/ aetiology unclear? Viral cardiomypathy Refer to Community Heart Failure Specialist Nurse team Review 4 months

34 CHFN review- how did he feel? Weight slight reduced 148kg B/P 138/88 Pulse 95 irreg Trace peripheral oedema ankles Chest clear Improved ++ since starting ACE I and BB Renal function check egfr > 90, K+ 4.1

35 CHFN role Titrate Bisoprolol to control rate mean 80bpm for AF, but..(discuss) Lifestyle support / encouragement- set realistic goals (signpost to dietician if he agrees/ time)- working to support family (minimal sick pay) Education/ advice re heart failure, medication, investigations (reassurance)

36 Thank you for listening Sandwell Community Heart Failure Team 4 th Floor Lyng Centre for Health and Social Care Frank Fisher Way West Bromwich West Midlands B707AW Tel: