Transcript The Challenges and Opportunities of Improving Heart

The Challenges and
Opportunities of Improving
Heart Failure Management in
the Community.
McIntyre et al (2002)
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“Heart failure care is fragmented due
to a lack of understanding between
primary and secondary care.”
Guidelines
“Rome wasn’t built in
a day”
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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
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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
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Hospital services congested, patient
experience often poor, diagnostics, treatment
and follow-up can be done in primary care.
Nicholson C, 2007
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CHF management is likely to be shared
between primary and secondary care
NICE 2003
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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
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Nicholson C, 2007
Health Care Commission
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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
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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?
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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.
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£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).
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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?
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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)
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CHF is a debilitating long-term illness and
exerts a heavy burden upon both the
individual and society.
Stewart S & Blue L 2001
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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)
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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
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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
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Pulmonary Crepitations
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Pleural Effusion
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Oedema, Ascites
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Raised JVP
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Valve Sounds
Symptoms
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Fatigue
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SOBOE
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Orthopnoea
 Acute SOB
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Loss of appetite
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Weight gain
The 3 Elements of HF
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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
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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
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RAAS
Adrenergic activation
ADH
Endothelins
Natriuretic peptides
How the heart reacts
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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
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What happens when there is too much
fluid in the body
BNP
Systolic or Diastolic HF
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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
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Diuretics (Symptom Control)
Inotropes (Rarely Used)
Vasodilators (Symptom Control)
Betablockers (Improve Outcomes)
ACE therapy (Improve Outcomes)
Spironolactone (Improves Outcomes)
Digoxin
Basic Management
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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)
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Widespread use
NICE 2003
guidelines
ICD management in
palliative care.
Achieving Cardiac Resynchronization
Goal: Atrial synchronous
biventricular pacing
Right Atrial
Lead
Left Ventricular
Lead
Right Ventricular
Lead
Doug Smith:
ICD
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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 rest
Class 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
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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
Local Strategies
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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).
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The Role of the Heart Failure Nurse
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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.
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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?
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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
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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.
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All palliative care but
Continue diet and fluid restrictions
Observe weight recordings
Consider ICD device
From Exercise………
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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
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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
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To make a real difference
To develop a robust service for the
future
To promote CHF management as a
community speciality
Referral Criteria
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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 Team
Rob Sharkey Heart Failure Specialist Nurse
Sue Leveridge Heart Failure Specialist Nurse
Dr Andrew Gallagher GPwSI
Please fax referrals to 01524-61443
Contact details Tel 01524-61443
Rosebank Medical Practice, Ashton Road, Lancaster LA1 4JS
[email protected]
[email protected]
[email protected]
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
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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
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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?