West Essex Frailty Pathway: Heart Failure

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Presentation transcript:

West Essex Frailty Pathway: Heart Failure Once therapy optimised consider ongoing review by primary care OR by community matron if ongoing poor symptom control Confirmed case of heart failure due to LV systolic dysfunction (LVSD) (Ejection Fraction <50%) Optimise medication with angiotensin therapy and beta blocker if tolerated – consider input by heart failure nurse for monitoring and titration of medication If acute onset increase in symptoms – assess severity (use (NEWS) Early Warning System to guide) – consider increase in diuretics for mild fluid overload and arrange ongoing review EWS ≥ 5 Evidence of severe exacerbation? Tachycardia hypotension, drowsiness, hypoxia, severe tachypnoea at rest EWS 1-4 Evidence of mild to moderate exacerbation? Admit to acute hospital (if this is not an expected terminal event in a patient on an end of life care pathway) Contact heart failure nurse for advice or urgent assessment if patient has social factors/care needs that could complicate management at home. Heart failure nurse can arrange same day face to face assessment or suggest/arrange urgent assessment via SPA at RAC or in community bed. SPA contact Monday to Friday 8am – 5pm for arranging admission 01279 827524 Community Specialist Heart Failure Nurses can: Assess and titrate cardiac meds for patients with confirmed LV systolic dysfunction. Once medication optimised will discharge back to community matrons and/or primary care for ongoing review Reassess if exacerbation of heart failure is evident Telehealth for appropriate patients Signpost to primary care and end of life teams if evidence of severe end stage disease is present and end of life can plan may be required Advice and guidance Single Point of Access (SPA) 08:00-21:00, Seven days a week Telephone: 01279 827524 Fax: 01279 827827 Email: sep-tr.SinglePointOfAccess@nhs.net