Transcript Integrated Heart Failure Nurse - Croydon Health Services NHS Trust

Long Term Conditions
Heart Failure
Integrated Heart Failure Team
What's changed?
2012
2013
Hospital
1 Heart Failure
Specialist Nurse
(GW)
Community
3 Heart Failure
Specialist Nurses
Integrated Service (Jan 2013)
Consultant Cardiologist
Clinical Fellow
4.5 Heart Failure Specialist
Nurses
Members of the Team
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Grace Williams
Tina Lawton
Alison Bentley
Jo Rungusumy
Vacancy
Judy Arnold
Janak Patel
Jade Brown
Team Leader 1.0 wte
HFNS 1.0 wte
HFNS 1.0 wte
HFNS 0.6 wte
HFNS 1.0 wte
Bank HFNS
Administrator
Administrator
The Team!
Heart Failure Clinical Team
• Dr Sanjay Kumar, Lead Consultant Cardiologist
• Dr Ravi Kamdar, Consultant Cardiologist in Device
Therapy, Arrhythmias, Heart Failure Consultant
• Dr Suzannah Wilson, SpR in Device Therapy,
Arrhythmias, Heart Failure Consultant
• Sally Massey Operations Manager, Specialist
Medicine, Cardiac & Respiratory, Adult Care
Pathways
• Dimitrios Karagkounis – CCG/CUH Pharmacist
• David Roskams, NHS Croydon CCG
Current Service Provision
• Hospital In-patient review
• Service Office
• Discharge Personal
Lennard Road
Management Plan (PMP)
Croydon, CR9 2RS
• Post discharge telephone
• Single point of contact follow-up within 2 weeks in
for patients and GP’s
Community
• Known pt. self referral • Weekly HF MDT inclusive
with Pharmacist
Current Service Provision
CLINICS
• CUH - Ad hoc
• Purley War Memorial Hospital – Monday/Friday
• Norbury HC-Wednesday
• Sanderstead Clinic - Thursday
• Woodside HC– Friday
• Parkway HC (Twice monthly )
HOME
• Domiciliary visits for those who cannot travel.
Role of the HF Nurse
• Working with local and national HF guidelines
• Using a clinical management plan
• Ensuring correct Evidence-based medication and up
titration, monitoring of symptoms , biochemistry and
observations .
• Ensuring appropriate investigations for HF have been
done.
• Referral on to a cardiology consultant if appropriate
• Case management of complex patients
Role of the HF Nurse
• Aim to reduce emergency admissions & and
length of stay.
• Improved quality of life for patients
• Patient empowered through education
towards self management of condition
• Reviewing those nearing end of life, liaison
with palliative care.
Current Referral Criteria
• Croydon based GP
• Confirmed diagnosis of heart failure on
Echocardiogram essential
• Left ventricular systolic dysfunction
• Preserved heart failure/diastolic
• HF with valve dysfunction
• HF with atrial fibrillation
Referrals Sources
• GPs
• CUH- Cardiology , Medicine , Care of the
Elderly etc.
• Tertiary centres - SGH, KGH and GSTT
• Referrals from MDT ( Rapid Response,
Community matrons, Health visitors for older
people , District nurses, Stroke team ,
Palliative care )
How to Refer to the IHFNS
• Referral form available on CHS website
http://www.croydonhealthservices.nhs.uk/Do
wnloads/GP_resources/Referral_information/
Cardiology/Croydon%20Heart%20Failure%20R
eferral%20Form.pdf
Heart Failure Service Redesign
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GP One Stop HF clinics move into Community
Telehealth Monitoring
Cardiac Rehabilitation
‘Hot Clinics’
Community IV diuretic therapy
Slide 1
Heart Failure Monitoring & EoLC
Heart failure diagnosis and personal
treatment plan in place agreed with patient.
BHF personal record for patient to self
manage condition.
Escalation plan if condition deteriorates.
Patient monitoring & review 6/12 months
depending on severity. Telehealth as
appropriate.
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1
Next slide
TRIGGER TOOL
Trigger assessment to help clinician and
patient determine stage of disease.
Establish base line.
1
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GP advised so additional
information can be sent to
MDT
Information
Patient satisfies two of the criteria on
the trigger tool. GP or HFSN to consider
whether reflects “end stage” HF
Adjust medication and seek
specialist treatment e.g.
Surgical management
biventricular pacing if
appropriate
MDT - Gold Services Framework/Risk
Stratification meetings in primary care
will include decisions regarding heart
failure patients
Palliative Care/End of Life pathway with
patient & family/carers. Coordinate My
Care record established
Patient choice regarding place of death
Steps that are based in primary care
Steps that are based in acute
Steps that are taken in community services
Decision making point
Shared decision making with patient
Own home
Care home
06/04/2015
Hospice
Timeline will be different for
all patients depending on
deterioration, so regular
monitoring by community
services clinicians will
continue based on needs.
Advance Planning and End of Life
• Gold Standard Framework
• Collaborative approach/Joint decision involving the
patient, significant other, the GP (Consultant
Physician/Cardiologist if an in-patient) and the HF
specialist
– Involvement of the Palliative care team, St Christopher’s
Hospice home support team
– Discussion regarding the preferred place of care (PPC) –
home, hospice, hospital and when to cease admissions for
decompensation of HF or complications related to HF
management. Facilitating discharge to die at home
• End-of life register- Co-ordinate my care (CMC)
TRIGGER TOOL TO RECOGNISE EoLC ( Brent Trigger Tool)
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.
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.
WEIGHT LOSS- GREATER THAN 10% WEIGHT LOSS OVER PAST SIX MONTHS.
GENERAL PHYSICAL DECLINE.
SERUM ALBUMIN <25G/L.
CHRONIC KIDNEY DISEASE (eGFR <15ml/min)
06/04/2015
PATIENTS WITH STAGE 4 OR 5 KIDNEY DISEASE WHOSE CONDITION IS DETERIORATING OR PATIENTS WHO
HAVE DECLINED OR DISCONTINUED DIALYSIS.
Future developments
• Aim to divide our
caseload to align with
GP Networks
• Work collaboratively by
strengthening links with
other community
services
• Attend GP MDT/Risk
stratification/GSF
Meetings
Contact details
We are available Monday – Friday, 09.00hrs –
17.00hrs
Lennard Road Office
Telephone: 020 8274 6416 or 6152
Fax: 020 8274 6174
Croydon University Hospital
Telephone: 020 8401 3000 Ext. 4413
Contact via switchboard 020 8401 3000, bleep 772
Any Questions?