1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. Heart Failure as Primary Diagnosis Coded as primary (Co+) HF team listed as primary (Cl+) Group 1 Not Coded as primary (Co-) HF team listed as primary (Cl+) Group 2 Coded as primary (Co+) HF team did not list as primary (Cl-) Group 3

8. Total Primary HF population all 3 groups n =130 Index n = 101 LVSD n = 59 Readmissions n = 29 LVSD n = 24

9. All Primary Index and Readmissions by Group

10. 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

11. 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

12. Groups 1 (Co+ Cl+) and 2 (Co- Cl+) Clinically LVSD 55 21 Index admission Readmission

13. Clinically Agreed LVSD (Cl+) Seen by HF Nurse Seen by Cardiologists 36 12 20 12 Index admission n=55 Readmission n=21

14. Clinically Agreed LVSD (Cl+) 17 50 Index admission Readmission Survived to discharge Index n= 55 Readmission n=21

15. Clinically Agreed LVSD (Cl+) 12 7 Index admission Readmission Under Active Care by HFSN at Admission Index n= 50 Readmission n=17

16. Clinically Agreed LVSD (Cl+) Index n= 50 Readmission n =17 17 11 45 12 On Admission ACE/ARB or Contraindicated On Discharge ACE/ARB or Contraindicated 41%85% == Index admission Readmission

17. Clinically Agreed LVSD (Cl+) Index n= 50 Readmission n =17 25 15 44 16 On Admission BB or Contraindicated On Discharge BB or Contraindicated 59%89% == Index admission Readmission

18. Clinically Agreed LVSD (Cl+) Index n= 50 Readmission n =17 5 10 30 14 On Admission MRA On Discharge MRA 22%65% == Index admission Readmission

19. Prescribing for LVSD

20. Coded Groups 1 (Co+Cl+) & 3 (Co+Cl-) n= 55 ACE63% BB60% MRA45% Triple Therapy27%

21. Prescribing for LVSD Coded Groups 1 (Co+Cl+) & 3 (Co+Cl-) n= 55 ACE63% BB60% MRA45% Triple Therapy27% National Average 2013-14 (Co+) England and Wales n= 38,257 ACE85% BB85% MRA51% Triple Therapy41%

22. Prescribing for LVSD Coded Groups n= 55 1 (Co+Cl+) & 3 (Co+Cl-) ACE63% BB60% MRA45% Triple Therapy27% Clinical Groups n= 67 1 (Co+Cl+) & 2 (Co-Cl+) ACE85% BB89% MRA65% Triple Therapy61% National Average 2013-14 England and Wales n= 38,257 ACE85% BB85% MRA51% Triple Therapy41%

23. Prescribing for LVSD Coded Groups n= 55 1 (Co+Cl+) & 3 (Co+Cl-) ACE63% BB60% MRA45% Triple Therapy27% Clinical Groups n= 67 1 (Co+Cl+) & 2 (Co-Cl+) ACE85% BB89% MRA65% Triple Therapy61% National Average 2013-14 England and Wales n= 38,257 ACE85% BB85% MRA51% Triple Therapy41% Patients known to HF nurses n= 19 ACE100% BB100% MRA95% Triple Therapy95%

24. 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

25. 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

26. 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