Transcript Developing rehabilitation for people with heart failure

Developing rehabilitation
for people with heart
failure
Evolving services in
Newcastle upon Tyne
Christine Baker
In the beginning….




Increasing prevalence of heart failure
People with heart failure are frequently admitted to
hospital
Heart failure is linked with poor prognosis and significant
impact on everyday life.
Growing evidence base:


Exercise is safe and beneficial for people with heart failure
NSF for CHD lists cardiac rehabilitation, risk factor advice,
physical activity and psychosocial interventions as key
interventions for people with heart failure
Figure 1 Hazard ratios and 95% confidence intervals for the individual studies for the
effect of exercise training on risk of death . (ExTraMatch collaborative, BMJ, 2004)
In Newcastle upon Tyne:



In 2003 there was no rehabilitation service for people
with heart failure
A group was set up to address heart failure in the acute
hospitals trust – supported piloting a specific
programme
We had available resources within the acute Hospitals
Trust
 A rehabilitation facility
 An experienced multi-disciplinary team
RVI rehab team
Cardiac rehabilitation nurse
 Physiotherapist and physiotherapy support
 Occupational therapist
 Pharmacist, cardiologist, psychologist,
dietician providing flexible input
 Administration support

An evolving model – service user
views
1. Information needs
 Individually
relevant
information
 Facts about heart
failure
 Coping with heart
failure
 Lifestyle change
 Dealing with others
 Practical advice
Process:
 involve family
members
 written information
 group discussion (not
talks)
 share information
2. Physical activity

Goal – to increase stamina and improve tolerance
for exercise so not so tired
Need for individualised exercise
 Home exercise plan
 Something to do daily
 Group to provide support

3. Relaxation
4. Time for peer support
Programme model





Condition (Heart failure) and evidence-based
To help participants develop knowledge, skills
and confidence to improve and sustain
achievable health and functional activity.
16 weekly sessions (2 hours)
Up to 12 participants, partners invited
Collaborative: participants actively involved in
planning programme, goal setting and
monitoring progress
Individual reviews
 A facilitated, personally set home-based
exercise programme, developed and
practiced at rehab.
 Activity plan and home diary to record and
monitor activity
 Relaxation approaches demonstrated
 Programme of discussion topics

Discussion topics








Understanding heart failure
Taking control of symptoms
Adjusting and coping
Managing at home
Medication
Approaches to food and eating
Exercise – what can I do
Social support and community resources
Participants: recruitment and
inclusion criteria







Potential participants identified by cardiologist
or ward sister
NYHA class 2 or 3
LV systolic dysfunction underlies heart failure
Stable for 4 weeks
Angina no worse than CCS 3, and been assessed
Reviewed in cardiology clinic
People with devices can be included
Exclusion criteria









NYHA class 4
Severe angina/ischemia
Uncontrolled heart failure, worsening symptoms
Change in treatment due to worsening condition
BP < 90 mmHg systolic, or < 100 if associated
dizziness
Resting heart rate>100 beats/min
Uncontrolled arrhythmias
Febrile illness
Cardiologist considers unsuitable
Evaluation
The participants
 4 men, 3 women
 Aged 43 – 79 years
 Class 3-4: 4 – Left ventricular
systolic dysfunction,
2 – cardiomyopathy
 Ejection fraction 20 – 72%
 Co-morbidity:
History of CHD (5),
renal impairment (3),
asthma (2), diabetes(2),
Hyperthyroidism (2),
Obesity (3), Peripheral vascular
disease(1)
Attendance
 2 did not engage in
group
 2 died in course of
programme
 3 regularly attended
whole programme
 Family members
attended







Relevant past medical 
history (NYHA class,

cause of heart failure,
ejection fraction, exercise

tolerance test
Medication

Weight

Orthopnoea (numbers of
pillows to sleep)
Nocturnal dyspnoea
Leg fatigue

Occupational therapy
functional assessment
Shuttle walk test
Hospital Anxiety and Depression
Scales
Minnesota Living with Heart
Failure Questionnaire
Personal goals
Any recent worsening of
symptoms (ankle swelling,
fatigue, dizziness, shortness of
breath, sleep problems)
Resting blood pressure, heart
rate, SaO2, respiratory rate
Participant
Measure
Pre-course
Post-course
1
Shuttle walk test
HADS - anxiety
HADS - Depression
Minnesota Living with HF
100m
1 (non-case)
1 (non-case)
missing
210m
4 (non-case)
2 (non-case)
40
2
Shuttle
HADS Anxiety
HADS Depression
Minnesota
300m
8 (non-case)
2 (non-case)
20
470m
8 (non-case)
4 (non-case)
17
3
Shuttle
HADS Anxiety
HADS Depression
Minnesota
80m
10 (borderline)
4 (non- case)
37
150m
15 (caseness)
3 ( non case)
31
4
Shuttle
HADS Anxiety
HADS Depression
Minnesota
10m
5 (non-case)
13 (caseness)
76
/
/
/
/
5
Shuttle
HADS Anxiety
HADS Depression
Minnesota
30m
17 (caseness)
10 (borderline)
61
/
/
/
/
6.
Shuttle
HADS Anxiety
HADS Depression
Minnesota
20m
14 (caseness)
10 (caseness)
49
/
/
/
(died)
(died)
Goal achievement
Common goals:
 To improve confidence
 To understand condition
 To increase energy levels
 To learn what I can do and how far to go
 To take up a specific activity
 To have a practical need met
Participants reported a good degree of goal
attainment
Participant feedback
Semi-structured interview


Altogether positive
Constructive:
Programme offered at diagnosis
 Opportunity to attend at intervals in future
 Issue of prognosis, palliative care and deaths
 Issue of maintenance
 Issue of support for family members

Staff feedback


Referrals –too few– Class 3 and 4: address referral
Collaborative approach -individual goal setting home-based programme– worked well
Develop rolling programme and flexible intervals for
participants – address maintenance/community links
 Develop written information
 Evaluation – Formal and sessional evaluation OK capture self-efficacy


Confidence and experience of staff has developed
Next steps




Further developing as a rolling programme
Cardiologists and BHF heart failure nurses
involved in recruitment
Evolving links with community services re.
maintenance
Continuing to evaluate
Taking control of Heart Failure
A community development
project
Taking control of Heart Failure
A community development project



Based in inner west of Newcastle-upon Tyne
Supported by grant from Health Action Zone:
partnership funding for preventative
programmes
Partnership of community and health (PCT)
providers
Taking control of heart failure
Model




Based on community development methods and
principals. Innovation-based.
Objective: to empower people to take more
control of their lives – to add value
Fundamentally a quality of life programme, not
a disease based programme
Participants determine programme structure and
outcome evaluation (no physiological measures)
Taking control of heart failure
Process





2 BHF funded HF nurses working with GPs and
practice nurse IHD leads from 2 practices
32 people with class 2 heart failure identified
Written invitation to participate – follow-up
telephone call
BHF nurses visiting willing people at home to
meet, provide information and discuss group.
Invitation to group.
Taking control of Heart Failure
Programme





2 closed groups
Ten weekly sessions
Facilitated by community development worker
with experience in such projects and group
facilitation
Content directed by group
Potential involvement of local cardiac rehab
team – pharmacist, psychologist, exercise
specialists, nutritionist
Over to you…