Published: 10/06/2014. Heart Failure Pathways

Transcription

1 Heart Failure Pathways

2 Diagnosing Heart Failure Page 1 of 2 Pa$ent presents with symptoms possibly due to heart failure, dyspnoea, fa$gue, exercise, intolerance, oedema History : Onset of symptoms (dura$on) dyspnoea, oedema and impact of ac$vi$es of daily living or at night. Past medical history & family history. Examina$on: General appearance, tachypnoea, tachycardia, basal pulmonary crackles, high JVP, hepatomegaly, ascites, pi6ng peripheral oedema. 50% of heart failure pa$ents are not recognised with breathlessness & swollen ankles (South London Cardiac Stroke Network) Afro-Caribbean popula$ons develop heart failure at a younger age, well under 65 yrs. Signs & symptoms suggest acute heart failure, decompensated chronic heart failure or other cardiac event. Severe dyspnoea or respiratory distress, chest pain, Consider other diagnosis e.g. (A) Pulmonary embolism, angina equivalent dyspnoea, lung disease, obesity or poor fitness, anxiety or renal failure Suspected heart failure *NYHA (New York Heart Associa$on) classifica$on tool to determine severity Previous MI (Myocardial infec$on) Refer within 2 weeks One Stop HF Clinic Consultant lead, HFSN, Specialist Assessment and Doppler Echocardiogram Connued on page 2 palpita$ons, cool clammy skin, cyanosis or arrhythmias Non heart failure diagnosis Immediate transfer to hospital for emergency - appropriate inves$ga$ons and management with referral as appropriate No Previous MI treatment Normal levels NTpro BNP < 400 pg/ml(47pmol/litre) HF unlikely Initial investigations Full blood count, urea & electrolytes, liver function, fasting lipids & glucose, thyroid stimulating and free thyroxin, urine analysis, peak flow or spirometry, chest X ray. 12 lead ECG with accurate interpretation and reporting. Measurement of BNP/NT pro BNP by all GPs Consider treatment: if HF likely and symptoms minor, NICE suggests Furosemide - Single 40mg dose and review within 4 days of ini$a$on - consider prescribing guidelines Connued on page 2 prescribing/pages/documents.aspx

3 Diagnosing Heart Failure Page 2 of 2 Connued from page 1 Ini$al inves$ga$ons Full blood count, urea & electrolytes, liver func$on, fas$ng lipids & glucose, thyroid s$mula$ng and free thyroxin, urine analysis, peak flow or spirometry, chest X ray. 12 lead ECG with accurate interpreta$on and repor$ng. Measurement of BNP/NT pro BNP by all GPs Normal Result NTproBNP<400pg/ml (47pmol/litre) (Refer to Page 1, Box (A). Consider treatment: if HF likely and symptoms minor, NICE suggests Furosemide - Single 40mg dose and review within 4 days of ini$a$on - consider prescribing guidelines hfp://nhscroydonintranet.croydonpct.nhs.uk/teamsanddepartments/primarycarecommissioning/ prescribing/pages/documents.aspx High levels of NTpro BNP >2000 pg/ml (236pmol/litre) Within 2 weeks Raised levels of NT pro BNP > 400pg/ ml 2000 pg/ml(47-236pmol/litre) Within 6 weeks Specialist confirms diagnosis of HF & ae$ology and ini$ates appropriate medical therapy. Educa$on and advice from HFSN. * See heart failure prescribing guidelines hfp://nhscroydonintranet.croydonpct.nhs.uk/teamsanddepartments/ primarycarecommissioning/prescribing/pages/documents.aspx Pa$ent monitored in primary/community se6ng with medicine $tra$on as appropriate and supported self management. Community Heart Failure Nurse Led Team: Providing community clinics, telephone contact to paents and clinicians, home visits. Personalised Management Plan, Educaon & advice, Tele-health monitoring in conjuncon with Community Matrons, Opmising prognosc medicaon, Liaison with Consultant Cardiologist (e.g. hospital HF MDT) and other specialists to manage co morbidity. Advance care planning as appropriate. Further inves$ga$ons as appropriate. Specialist treatment if appropriate e.g. Referral to transplant Unit, Inherited Cardiac Disease Clinic, Revascularisa$on, Biventricular pacemaker, defibrillator, cardioversion MDT - Risk stra$fica$on mee$ngs to review and manage challenging pa$ents and complete EOLC tool. EOLC iden$fied and referral to Pallia$ve One Stop Community Heart Failure Care Team Connued from page 1 Clinic Consultant lead with HFSN. Specialist Assessment and Doppler Echocardiogram Within 2 weeks Clinical decompensa$on threatening hospital admission Hospital inpatient with primary diagnosis of HF: Inpa$ent HF diagnosis/management pathway, including all appropriate inves$ga$on. Mul$-disciplinary assessment, including Cardiologist and HFSN. Personal management plan which includes a $tra$on plan to manage changes in medica$on as condi$on changes. Tele-health started for pa$ents mee$ng criteria. HF MDT involving HF Consultant, HFSN, Pallia$ve Care nurse. Hot Clinic same or next working day specialist assessment Day case treatment to prevent hospital admission.

4 Heart Failure Monitoring & EOLC Pathway Page 1 of 2 Heart failure diagnosis and personal treatment plan in place agreed with pa$ent. BHF personal record for pa$ent to self manage condi$on. Escala$on plan if condi$on deteriorates. Pa$ent monitoring & review 6/12 months depending on severity. Telehealth as appropriate. Trigger assessment to help clinician and pa$ent determine stage of disease. Establish base line. ***(Insert link for trigger tool here)*** (see page 2 for trigger tool) GP advised so addi$onal informa$on can be sent to MDT Pa$ent sa$sfies two of the criteria on the trigger tool. GP or HFSN to consider whether reflects end stage HF Informa$on MDT - Gold Services Framework/Risk Stra$fica$on mee$ngs in primary care will include decisions regarding heart failure pa$ents Adjust medica$on and seek specialist treatment e.g. Surgical management biventricular pacing if appropriate Pallia$ve Care/End of Life pathway with pa$ent & family/carers. Coordinate My Care record established Pa$ent choice regarding place of death Own Home Care Home Hospice

5 Heart Failure Monitoring & EOLC Pathway Page 2 of 2 TRIGGER TOOL TO RECOGNISE EoLC ( Appendix one) THE AIM OF THE TRIGGER TOOL IS TO HELP THE CLINICIAN IDENTIFY THOSE PATIENTS WHO MAY BE ENTERING THE FINAL STAGES OF HEART FAILURE. IF THE PATIENT MEETS TWO OR MORE OF THE FOLLOWING CRITERIA THE CLINICIAN SHOULD CONSIDER DISCUSSING THE PATIENT AT THE MULTI-DISCIPLINARY TEAM MEETING. SPECIFIC CHRONIC HEART FAILURE TRIGGERS THE PATIENT WITH ADVANCED DISEASE MAKES A CHOICE FOR COMFORT CARE ONLY, NOT PROGNOSTIC TREATMENT. THREE ADMISSIONS (into any of the following services - Hospital/ Intermediate Care Beds/Rapid Response Team) WITHIN THE PAST YEAR WITH SYMPTOMS OF HEART FAILURE. NEW YORK HEART ASSOCIATIONCLASS III OR IV, SHORT OF BREATH AT REST OR ON MINIMAL EXERTION DESPITE MAXIMAL MEDICAL THERAPY. DIFFICULT PHYSICAL OR PSYCHOLOGICAL SYMPTOMS DESPITE MAXIMAL MEDICAL THERAPY. GENERAL PREDICTORS OF END STAGE ILLNESS WEIGHT LOSS- GREATER THAN 10% WEIGHT LOSS OVER PAST SIX MONTHS. GENERAL PHYSICAL DECLINE. SERUM ALBUMIN <25G/L. RENAL DISEASE CHRONIC KIDNEY DISEASE (egfr <15ml/min) PATIENTS WITH STAGE 4 OR 5 KIDNEY DISEASE WHOSE CONDITION IS DETERIORATING OR PATIENTS WHO HAVE DECLINED OR DISCONTINUED DIALYSIS.

6 Managing Heart Failure Pathway Page 1 of 1 Pa$ent managed in primary/community se6ng unless requires - Specialist treatment which improves symptoms &/or prolongs life Management of severe heart failure (NYHA class IV) Heart failure that does not respond to treatment Heart failure can no longer be managed effec$vely in the home Offered annual Flu vaccina$on plus one off pneumococcal. LIFESTYLE Work-flying or driving issues. Sensi$ve issues regarding sexual ac$vity. Mental Wellbeing Access to Psychological therapies for pa$ents requiring support se6ng Pa$ent educa$on provided is evidence based and tailored to pa$ents needs Rehabilita$on through group supervised evidence based programme for all appropriate heart failure pa$ents. Lifestyle coaching for exercise, weight management and smoking cessa$on Heart failure diagnosis confirmed and pa$ent advised of severity of Smoking cessa$on course. condi$on to make informed decision about care. Telehealth introduced as appropriate. Alcohol advice and guidance healthy ea$ng. Cardiac Rehabilita$on Pharmacological treatment of heart failure in line with Croydon guidelines. See link for co morbidi$es, lipid modifica$on and hypertension hfp://nhscroydonintranet.croydonpct.nhs.uk/ TeamsAndDepartments/primarycarecommissioning/ prescribing/pages/documents.aspx Heart Failure with preserved left ventricular ejection fraction Treatment: Hypertension (ACEi, ARB, β-blocker) Conges$on (loop diure$c) Management according to severity and stage of heart failure using NYHA. Assessment using Brent Trigger Tool Pilot for EoLC benchmark. Heart failure with reduced leq ventricular ejec$on frac$on (LVEF 40%) Co-morbidi$es e.g. Diabetes, Angina/ Ischaemia (consider revascularisa$on), Arrhythmia, Renal failure Control ventricular rate in AF. Second line treatment seek specialist advice if pa$ent remains symptoma$c and on op$mal medical therapy Refer to Community cardiology service if non cardiac causes excluded and NYHA IV. Symptoma$c with reduced LVEF NYHA class II-III, stage C First-line Medical Therapy: Loop diure$c to reduce conges$on ACE inhibitor e.g. Ramipril ARB if ACEi-intolerant e.g. Candesart HF Licensed β-blockers e.g. Bisoprolol, Carvedilol. See specialist advice if symptoma$c and LVEF <35% TeamsAndDepartments/ primarycarecommissioning/prescribing/pages/ Documents.aspx Asymptoma$c with reduced LVEF NYHA class I, stage B Guideline based Medical therapy; Loop diure$c to reduce conges$on (Furosemide) ACE inhibitor (HF licensed ARB if ACEi-intolerant HF licensed β-blocker Lifestyle modifica$ons