1. Karen Cradock, B. Physio, MSc. Therapy Lead
The Heart Failure Clinical Programme and it’s impact on Cardiac Rehabilitation
Karen Cradock, B. Physio, MSc.
Therapy Lead

2. The scale of Heart Failure in Ireland ~ 300,000 people with ‘LV Dysfunction’; more than 100,000 with HF 2
IHF 2001

3. The Heart Failure Pyramid
HF patients with a history of admission
Symptomatic HF in the community
Asymptomatic Ventricular dysfunction
15,000 – Sick HF
85,000 – Stable HF
250,000 – Impending HF
The population in Ireland affected by heart failure can be drawn into three major groups:
1. There are an estimated 12,000 people forming the most severe category, the “sick HF” group; because of frequent and costly admissions to hospitals consume the majority of resources of HF care. Currently, there is no widely implemented, co-ordinated care strategy for the management of these people.
2. The second category have milder disease, are being treated in general practice but have not yet entered the cycle of admission and readmission for HF. There is no co-ordinated care strategy here and other difficulties in managing this group of people include high rates of mis-diagnosis and under-treatment.
3. The third group have left ventricular systolic dysfunction or impending heart failure without symptoms. These are frequently not treated, or even recognised.
The estimated annual numbers moving from stages 3 to 2 to 1 are shown. 3

5. Heart Failure: Problems and Solutions
Life Cycle Ideal :
85 yrs
40 yrs
Life Cycle with Heart Failure:
At Risk
First
Diagnosis
Hospitalisations
75 yrs
40 yrs
Prevention
Community Mx
Hospital

6. Heart Failure Solution
Life Cycle of Heart Failure in 2011:
Hospitalisations
40 yrs
75 yrs
Life Cycle with Heart Failure Programme:
76 yrs
40 yrs

7. OVERARCHING AIM TO IMPROVE QUALITY OF LIFE FOR
PATIENTS WITH HEART FAILURE
IN IRELAND

8. Objectives
Access
Every patient with symptoms of heart failure is diagnosed correctly and without delay
Quality
Every patient with heart failure is managed within a structured programme
Implement targeted programme to prevent heart failure
Cost
Reduce recurrent admissions by 1,000 with additional impact on de novo admissions
Reduce length of stay saving 20,000 hospital days per year

9. IMPLEMENTATION OF PROGRAMME
Heart Failure Clinical Lead
2 WTE Heart Failure Nurses in hospitals accepting acute admissions (1.5 WTE HFN in hospitals with mainly non acute admissions and providing out patient services)
Administrative support available
Adequate clinical space to see patients available
Structures in place for timely access to BNP and echocardiography
Access to therapy services

10. ECG, BNP, Bloods, QoL Measures Week 3 Week 4 Week 5 Week 6
Inpatient
2-3 visits
Self care management
Week 1
Week 2
Clinic visit
ECG, BNP, Bloods, QoL Measures
Week 3
Week 4
Week 5
Week 6
Education – review of medications
Week 7
Week 8
Week 9
Week 10
Week 11
Tel
Week 12
ECHO, bloods, HADs, enrolled in rehabilitation programme
Note: Access to Monday to Friday 5 day per week clinic for unscheduled visit

11. Active National Programmes
St. Vincent’s University Hospital
Tallaght Hospital
St. James Hospital
Mater Hospital
Beaumont Hospital
Our Lady of Lourdes Hospital, Drogheda
Wexford General Hospital
Galway University Hospital
Portiuncula Hospital, Ballinasloe

12. Key performance indicators
Target 2012
Metric August 2012
Rate of readmission for heart failure within 3 months following discharge from hospital
≤ 27%
6.3%
Median Length of Stay for patients admitted with a principal diagnosis of ADHF
≤ 7.0 days
8.0 days
Percentage of patients with ADHF who are seen by the Heart Failure Clinical Lead during their hospital stay
>65%
92.3%
N = 427*

13. 42.3% less emergency GP visits in the intervention arm
Adherence
Outcome
Follow up
Courtney 2009
RCT (blinded)
Intervention n=58
Control n= 64
Mean age 78.8±6.8 years
Muscle strengthening, balance training, walking, muscle stretching. Assessed by PT.
HV by Nurse 48 hours post DC weekly follow up calls X 4 weeks, monthly telephone follow up X 5 months
53% of intervention arm training at 6 months
24% less admissions to ED in the intervention arm
42.3% less emergency GP visits in the intervention arm
21 readmissions in the intervention with 49 in the control
7 months
Wierzchowlecki 2006
RCT
Intervention n=80
Control n =80
HFU visit day 14, and at 1,3,6 and 12 months
Access to cardiologist, HF CNS, Psychologist , Physio
Control; Primary physician
Reduced hospital admissions by 37%
Reduced hospital readmissions with HF by 48%
Mean duration of hospitalisation I= 9.3 days C=12.5days
1 year
Austin 2008
n=112
SC=55
CR= 57
Cardiac rehabilitation (twice weekly) 8 week MDT programme. This was followed by a 16 week community based exercise class V standard HF follow up
Number of inpatient days was 50% lower in CR group
I=4.1days
C=8.4days
Survival was 32 months in CR group V 23 months in SC group.
5 years

14. Davidson 2010
n=105 RCT
12 week once per week tailored MDT programme
All cause hospitalisation;
I = 25
C=35
P<
Cardiovascular events;
I=24%
C=55%
Mortality: 79% alive in the usual care V 93% in the intervention arm
5 year follow up
Reed 2010
HF Action
I = 1159
UC=1172
36 supervised exercise sessions
Hospitalizations I=2297
UC=2332
LOS
I= 13.6days
UC=15 days
Total medical cost
I=50,857 dollars
UC=56,177 dollars
Cost of intervention 1000
2.5 years

15. Cochrane Review- Exercise based Rehabilitation for Heart Failure
Follow up
HRQoL
Significance
HF- ACTION (2009)
30 months
KCCQ
P<0.001
Austin (2005)
6 months
MLWHF
EQ-5D
P<0.0001*
P<0.01*
5 years
P<0.001*
P=0.12*
Bellardinelli (1999)
15months
19 months

16. Model A
Heart Failure team manage the service
Model B
Integration of cardiac rehabilitation and heart failure services

18. Training Heart Failure Nursing Professional Certificate UCD
On-going course – intake annually
(FETAC level 9)
Advanced Skills Training for Physiotherapists in Heart Failure
Commenced in September 2012 – 6 months training (Aspiring to FETAC level 9 )
Pharmacy Training Programme
Undergoing development
Foundation Course
In the discussion phase (Possibly e-learning)

20. Units planning for implementation of the National Heart Failure Programme (Sept 2012)
Connolly Hospital
Cavan/Monaghan Hospital Group
Mid Western Regional Hospital, Limerick
Sligo General Hospital

21. Impact of Programme on Cardiac Rehabilitation
All current programme sites have cardiac rehabilitation programmes- likely to be referred- will they be included in the group sessions?
Can cardiac rehabilitation become integral part of this care structure?