1. St Albans and Harpenden PCT Heart Failure Service Dr Kate Mackay Director of Public Health

2. Heart Failure Service NSF Coronary Heart Disease Standard 11

3. NSF Standard 11 Doctors should arrange for people with suspected heart failure to be offered appropriate investigations (including electrocardiography, echocardiography) that will confirm or refute the diagnosis. For those in whom heart failure is confirmed, its cause should be identified – the treatments most likely to both relieve symptoms and reduce their risk of death should be offered.

4. NSF Standard 11 Milestone 2 By April 2001, every primary care team should have: A systematically developed and maintained practice-based CHD register, including people with heart failure, and actively used to provide structured care to people with CHD

5. NSF Standard 11 Milestone 3 By April 2003 every primary care team should have: A protocol describing the systematic assessment, treatment and follow-up of people with heart failure agreed locally and being used to provide structured care to people with heart failure.

6. PCT Health Plan Heart Failure NUMBER ONE PRIORITY Hertfordshire Health Economy is considerably behind the NSF Milestone for Heart Failure. There is an urgent need:  To train GPs in the management of heart failure in order to redesign the model of care across primary and secondary care;

7. PCT Health Plan  For new investment in B-type natriuretic peptide (BNP) testing as a screening tool for heart failure before using echocardiography. BNP testing has an almost 100% accuracy for negative values. This would reduce the number of unnecessary echocardiograms.  To increase the provision of echos. Training for one GP as a Specialist per PCT to provide this is necessary.

8. PCT Health Plan  For “outreach” follow-up by specialist nurses to provide care at the primary/secondary interface.  For written protocols for heart failure diagnosis and management.  To include people with heart failure on the CHD register.  To provide specialist palliative care nurses for heart failure and to provide multi-disciplinary support.

9. Heart Failure Service  Revenue funding agreed in the Health Plan for 2003/4  Capital funding for echocardiograph secured Autumn 2003  GPwSPi appointed late 2003  2 Heart Failure Specialist nurses appointed early 2004  Echo ordered April 2004  Service to be provided within Runcie Unit St Albans City Hospital

10. Heart Failure & BNP Dr Richard Pile GPwSI in Heart Failure

11. Heart Failure – the facts Syndrome resulting from any structural or functional cardiac disorder that impairs the ability of the heart to function as a pump 900, 000 people in the UK 1 in 35 people aged 65-74 1 in 7 aged over the aged of 85 Commonest cause in UK is CHD 40% die within the first year of diagnosis

12. Heart Failure.. more facts! average GP looks after 30 patients with heart failure Diagnosis suspected in >10 new patients per year Costs the NHS £716 million per year 2% of NHS inpatient bed days, and 5 % of acute medical admissions This is going to increase in future

13. Management of Heart Failure NICE guidance published 2003 for adult patients with chronic heart failure aims to symptoms/signs/Ix to establish Dx also gives guidance on the treatment, monitoring and support of patients with heart failure. http://www.nice.org.uk/pdf/CG5NICEguide line.pdfhttp://www.nice.org.uk/pdf/CG5NICEguide line.pdf

14. NICE algorithm

15. Brain Natriuretic Peptide It’s difficult to diagnose heart failure clinically ECG can be used to rule out but requires confidence and competence in interpretation BNP is a potential aide to diagnosis: –Released from cardiac ventricles in response to stretching of chambers –Good test for ruling out heart failure (negative predictive value = 98%) –Correlates with ejection fraction and prognosis

16. Heart failure care pathway – stage 1 1.New suspected heart failure (NOT for retrospective checking of practice register) 2.Investigation including ECG and BNP 3.If either of above abnormal, refer to secondary care for cardiac opinion/ECHO (as per GMS 2!) 4.Diagnosis made, advice re management and follow up as appropriate

17. Heart Failure care pathway – Stage 2 Direct access to GPwSI-led Heart Failure clinic, unless patient has exclusion criteria ECHO done, to assess predominantly LV function. Info given to patient, introduction to Heart Failure nurses if diagnosis confirmed Management plan, support and follow up for patient and PHCT arranged. Involvement of secondary care as necessary.

18. Heart failure care pathway - Summary Heart failure is a common, complex and serious syndrome It is difficult to diagnose clinically, and to manage We can improve the diagnosis, investigation, management, and outcome for our patients This local service is now being implemented to facilitate this, predominantly in a primary care/community setting

19. Heart Failure clinical team PRIMARY CARE: –Richard Pile – GPwSI in Heart Failure –Gail Stevens – Heart Failure nurse –Lindsay Farmer – Heart failure nurse SECONDARY CARE: –John Bayliss – Consultant cardiologist –Gillian Harding – Cardiology lead nurse –Chandra Ratnarajah – Heart failure liason nurse

20. The Role of the Heart Failure Nurse

21. Aims of the service Patient-specific objectives Service-specific objectives Financial advantages

22. Aims of the service To improve the post-discharge management of patients with chronic heart failure. To improve the quality of life of patients with chronic heart failure To avoid unnecessary hospital readmissions To provide seamless care between primary and secondary care

23. Patient-specific objectives To assess patients in their home environment and plan for their future needs in accordance with the service guidelines To review the prescribed medication regimen to ensure that patients receive appropriate pharmacotherapy in effective doses. To work to agreed prescription guidelines drawn up in conjunction with general practitioners and cardiologists

24. To monitor the patient's clinical status and blood chemistry following medication changes To ensure appropriate and effective communication between the patient, general practitioner, carer, ambulance services, hospital, social services, and all other health- care professionals involved in the patient's care To provide patients, families, and carers with tailored education, advice, and support.

25. To act as a resource for other health-care professionals involved with the patient. To advise the patient on life-style changes that would be advantageous to their health To encourage patients (and their family or carers as appropriate) to be actively involved in managing and monitoring their own care To provide easy access for patients, family, and carers to contact the specialist nurse in order to detect and treat early clinical deterioration before symptoms become severe

26. Service-specific objectives To ensure that the overall nursing and medical care provided keeps pace with research evidence To monitor, evaluate, and audit the service at regular intervals to ensure both a high standard of care and the effectiveness of the service as a whole in improving health outcomes. To facilitate effective links with other health- care services relevant to the care of the patient with chronic heart failure

27. Can we afford not to implement?