Transcript Jenny Welstand HF Audit for All Wales meeting 17 11 15x

Heart Failure Audit
Dr Jenny Welstand
Lead Nurse Heart Failure Service
Wrexham Maelor Hospital
Acknowledgements:
•North Wales Cardiac Network
•Dr Richard Cowell and Specialist Cardiac Nurses – charitable funds
•Servier Pharmaceuticals
•Clinical audit and effectiveness department
Sue Yorthworth
Presentation
• NICOR National HF Audit Headlines
– Patients with a primary diagnosis of HF as coded
at discharge for Patient Episode Database for
Wales (PEDW)
• Reliability of data
– Are patients with LVSD admitted to Maelor treated
effectively?
• Inpatient project; clinical HF V’s coded HF
– 6-months data May-October 2014
– Focus on prescribing patterns
Key Summary Points NICOR; HF
• Quality improvement focuses on unscheduled
admissions; primary diagnosis only
– Outcomes consistently poor for those receiving
sub-optimal care
• What significantly improves prognosis and life
expectancy:
– Input from HF specialists
– Being cared for on a cardiology ward
– Evidenced-base HF therapies; Triple therapy
Welsh Data vs English Data
• Still a lower % of patients entered but this is
annually increasing
• Welsh Data compare favourably with English
for treatment
– apart from access to HFNS; decreased morbidity
and mortality benefits for Welsh patients
Inpatient Project Methodology
• Prospectively sought to identify all patients
admitted with clinical HF throughout the
Maelor over 1-year
– All medical wards to have weekly visit
– Band 6 nurse – part-time
• Collecting data and providing information
– Patient held care plan
– Nursing care plan; weight chart
– Advice to medical team; echo, medications
Definitions
• Identified patients entered onto database
– Index Admission
– Readmission
• Patients assigned as either primary or
secondary diagnosis
– “Was the main focus of treatment for the
symptoms of HF irrespective of aetiology”
• Validating Data
– Dr Richard Lawrance and Dr Jenny Welstand
Heart Failure as Primary Diagnosis
Group 1
• Coded as primary (Co+)
• HF team listed as primary (Cl+)
Group 2
• Not Coded as primary (Co-)
• HF team listed as primary (Cl+)
Group 3
• Coded as primary (Co+)
• HF team did not list as primary (Cl-)
Total Primary HF population
all 3 groups n =130
Index
Readmissions
n = 101
n = 29
LVSD
LVSD
n = 59
n = 24
All Primary Index and Readmissions by Group
80
79
70
60
50
52
40
Index
LVSD
30
36
20
24
10
15
0
9
Group 1 Co+ Cl+
Group 2 Co- Cl+
Group 3 Co+ Cl-
Group 2; Clinically Identified
Cl+ Co• Identified 36 patients with HF as a primary
diagnosis not captured by PEDW coding
– 24 patients had LVSD
• Coding department undertaking validation
exercise as part of our 1-year project
• We identified an additional 46% of pts with
primary diagnosis of HF
Group 3; Coded HF
Co+ Cl• Coding is Retrospective; 4-month delay
• Mis-coded patients
– NICOR discussion with clinical coding and remove
– N=10-15 Dr Richard Lawrance recorded in case
notes
• Group 3 HF n= 15; LVSD n= 9
– We had coded as secondary N= 7
– validated by Dr Richard Lawrance
Groups 1 (Co+ Cl+) and 2 (Co- Cl+)
Clinically LVSD
Index
admission
55
21
Readmission
Clinically Agreed LVSD (Cl+)
• Seen by HF Nurse
Index admission n=55
36
• Seen by Cardiologists
Index admission n=55
20
12
Readmission n=21
12
Readmission n=21
Clinically Agreed LVSD (Cl+)
Index n= 55
Readmission n=21
Survived to discharge
Index admission
50
17
Readmission
Clinically Agreed LVSD (Cl+)
Index n= 50
Readmission n=17
Under Active Care by HFSN at Admission
Index admission
7
12
Readmission
Clinically Agreed LVSD (Cl+)
Index n= 50
Readmission n =17
On Admission
ACE/ARB or Contraindicated
On Discharge
ACE/ARB or Contraindicated
Index admission
Index admission
17
45
11
12
Readmission
Readmission
=
=
41%
85%
Clinically Agreed LVSD (Cl+)
Index n= 50
Readmission n =17
On Admission
BB or Contraindicated
On Discharge
BB or Contraindicated
Index admission
Index admission
25
44
15
16
Readmission
Readmission
=
=
59%
89%
Clinically Agreed LVSD (Cl+)
Index n= 50
Readmission n =17
On Admission
MRA
Index admission
On Discharge
MRA
Index admission
5
30
10
14
Readmission
Readmission
=
=
22%
65%
Prescribing for LVSD
Prescribing for LVSD
Coded Groups
1 (Co+Cl+) & 3 (Co+Cl-)
n= 55
ACE
63%
BB
60%
MRA
Triple Therapy
45%
27%
Prescribing for LVSD
Coded Groups
1 (Co+Cl+) & 3 (Co+Cl-)
n= 55
ACE
63%
BB
60%
National Average 2013-14
(Co+) England and Wales
n= 38,257
ACE
85%
BB
85%
MRA
Triple Therapy
MRA
Triple Therapy
45%
27%
51%
41%
Prescribing for LVSD
Coded Groups n= 55
1 (Co+Cl+) & 3 (Co+Cl-)
ACE
BB
63%
60%
MRA
Triple Therapy
45%
27%
Clinical Groups n= 67
1 (Co+Cl+) & 2 (Co-Cl+)
ACE
85%
BB
89%
MRA
65%
Triple Therapy
61%
National Average 2013-14
England and Wales n= 38,257
ACE
85%
BB
85%
MRA
51%
Triple Therapy
41%
Prescribing for LVSD
Coded Groups n= 55
1 (Co+Cl+) & 3 (Co+Cl-)
ACE
BB
63%
60%
MRA
Triple Therapy
45%
27%
National Average 2013-14
England and Wales n= 38,257
ACE
85%
BB
85%
MRA
51%
Triple Therapy
41%
Patients known to HF nurses
n= 19
Clinical Groups n= 67
1 (Co+Cl+) & 2 (Co-Cl+)
ACE
85%
ACE
100%
BB
89%
BB
100%
MRA
65%
MRA
95%
Triple Therapy
61%
Triple Therapy
95%
Referrals to HFSN Team
• Other additional referrals to our team during
this six-month period n= 113
– Outpatients
– Echo diagnostic clinic
– GPs
– Specialist nursing colleagues
– Community nursing colleagues
– Patients/family
Equity of Access; what can we learn?
• National HF Audit does not adequately
capture management of unscheduled
admissions to judge quality
• Better outcomes if you are under care of HFNS
team
– Seeking patients and push therapies
– Alerting cardiology colleagues to patients with
complex problems
Take Home Thoughts
• If your Mum is admitted contact local HFNS
– Do you have a service?
• Do we adequately focus on aiming for triple
therapy?
– Longer length of stay
• Do primary care know what the plan is at d/c?
• Don’t under estimate time to undertake data
cleaning complex audit
– Thanks to Richard Lawrance encouragement and
support