Developing Developing rehabilitation for rehabilitation for people with heart people with heart

failurefailureEvolving services in Evolving services in Newcastle upon TyneNewcastle upon Tyne

Christine BakerChristine Baker

In the beginning….In the beginning…. Increasing prevalence of heart failureIncreasing prevalence of heart failure People with heart failure are frequently People with heart failure are frequently

admitted to hospitaladmitted to hospital Heart failure is linked with poor prognosis Heart failure is linked with poor prognosis

and significant impact on everyday life. and significant impact on everyday life. Growing evidence base:Growing evidence base:

Exercise is safe and beneficial for people with Exercise is safe and beneficial for people with heart failureheart failure

NSF for CHD lists cardiac rehabilitation, risk NSF for CHD lists cardiac rehabilitation, risk factor advice, physical activity and psychosocial factor advice, physical activity and psychosocial interventions as key interventions for people with interventions as key interventions for people with heart failureheart failure

Figure 1 Hazard ratios and 95% confidence intervals for the individual studies for the effect of exercise training on risk of death . (ExTraMatch collaborative, BMJ, 2004)

In Newcastle upon Tyne:In Newcastle upon Tyne: In 2003 there was no rehabilitation service In 2003 there was no rehabilitation service

for people with heart failurefor people with heart failure A group was set up to address heart failure in A group was set up to address heart failure in

the acute hospitals trust – supported piloting the acute hospitals trust – supported piloting a specific programmea specific programme

We had available resources within the acute We had available resources within the acute Hospitals TrustHospitals Trust

A rehabilitation facility A rehabilitation facility An experienced multi-disciplinary teamAn experienced multi-disciplinary team

RVI rehab teamRVI rehab team

Cardiac rehabilitation nurseCardiac rehabilitation nurse Physiotherapist and physiotherapy Physiotherapist and physiotherapy

supportsupport Occupational therapistOccupational therapist Pharmacist, cardiologist, Pharmacist, cardiologist,

psychologist, dietician providing psychologist, dietician providing flexible inputflexible input

Administration supportAdministration support

An evolving model – service An evolving model – service user user viewsviews1. Information needs1. Information needs Individually Individually

relevant relevant informationinformation

Facts about heart Facts about heart failurefailure

Coping with heart Coping with heart failurefailure

Lifestyle changeLifestyle change Dealing with othersDealing with others Practical advicePractical advice

Process:Process: involve family involve family

membersmembers written written

informationinformation group discussion group discussion

(not talks) (not talks) share share

informationinformation

2. Physical activity2. Physical activity Goal – to increase stamina and improve Goal – to increase stamina and improve

tolerance for exercise so not so tiredtolerance for exercise so not so tired Need for individualised exerciseNeed for individualised exercise Home exercise planHome exercise plan Something to do dailySomething to do daily Group to provide supportGroup to provide support

3. Relaxation3. Relaxation

4. Time for peer support4. Time for peer support

Programme modelProgramme model Condition (Heart failure) and evidence-Condition (Heart failure) and evidence-

basedbased To help participants develop knowledge, To help participants develop knowledge,

skills and confidence to improve and skills and confidence to improve and sustain achievable health and functional sustain achievable health and functional activity.activity.

16 weekly sessions (2 hours) 16 weekly sessions (2 hours) Up to 12 participants, partners invitedUp to 12 participants, partners invited Collaborative: participants actively Collaborative: participants actively

involved in planning programme, goal involved in planning programme, goal setting and monitoring progresssetting and monitoring progress

Individual reviewsIndividual reviews A facilitated, personally set home-A facilitated, personally set home-

based exercise programme, based exercise programme, developed and practiced at rehab.developed and practiced at rehab.

Activity plan and home diary to Activity plan and home diary to record and monitor activityrecord and monitor activity

Relaxation approaches Relaxation approaches demonstrateddemonstrated

Programme of discussion topicsProgramme of discussion topics

Discussion topicsDiscussion topics Understanding heart failureUnderstanding heart failure Taking control of symptomsTaking control of symptoms Adjusting and copingAdjusting and coping Managing at homeManaging at home MedicationMedication Approaches to food and eatingApproaches to food and eating Exercise – what can I doExercise – what can I do Social support and community Social support and community

resourcesresources

Participants: recruitment Participants: recruitment and inclusion criteriaand inclusion criteria

Potential participants identified by Potential participants identified by cardiologist or ward sistercardiologist or ward sister

NYHA class 2 or 3NYHA class 2 or 3 LV systolic dysfunction underlies heart LV systolic dysfunction underlies heart

failurefailure Stable for 4 weeksStable for 4 weeks Angina no worse than CCS 3, and been Angina no worse than CCS 3, and been

assessedassessed Reviewed in cardiology clinicReviewed in cardiology clinic People with devices can be includedPeople with devices can be included

Exclusion criteriaExclusion criteria NYHA class 4NYHA class 4 Severe angina/ischemiaSevere angina/ischemia Uncontrolled heart failure, worsening Uncontrolled heart failure, worsening

symptomssymptoms Change in treatment due to worsening Change in treatment due to worsening

conditioncondition BP < 90 mmHg systolic, or < 100 if associated BP < 90 mmHg systolic, or < 100 if associated

dizzinessdizziness Resting heart rate>100 beats/minResting heart rate>100 beats/min Uncontrolled arrhythmiasUncontrolled arrhythmias Febrile illnessFebrile illness Cardiologist considers unsuitableCardiologist considers unsuitable

EvaluationEvaluation The participantsThe participants 4 men, 3 women4 men, 3 women Aged 43 – 79 yearsAged 43 – 79 years Class 3-4: 4 – Left Class 3-4: 4 – Left

ventricular systolic ventricular systolic dysfunction, dysfunction, 2 – cardiomyopathy2 – cardiomyopathy

Ejection fraction 20 – 72%Ejection fraction 20 – 72% Co-morbidity: Co-morbidity:

History of CHD (5), History of CHD (5), renal impairment (3), renal impairment (3), asthma (2), asthma (2), diabetes(2), diabetes(2), Hyperthyroidism (2), Hyperthyroidism (2), Obesity (3), Peripheral Obesity (3), Peripheral vascular disease(1)vascular disease(1)

AttendanceAttendance 2 did not engage in 2 did not engage in

groupgroup 2 died in course of 2 died in course of

programmeprogramme 3 regularly 3 regularly

attended whole attended whole programmeprogramme

Family members Family members attendedattended

Relevant past medical history (NYHA class, cause of heart failure, ejection fraction, exercise tolerance test

Medication Weight Orthopnoea (numbers of

pillows to sleep) Nocturnal dyspnoea Leg fatigue Occupational therapy

functional assessment

Shuttle walk test Hospital Anxiety and Depression

Scales Minnesota Living with Heart

Failure Questionnaire Personal goals Any recent worsening of

symptoms (ankle swelling, fatigue, dizziness, shortness of breath, sleep problems)

Resting blood pressure, heart rate, SaO2, respiratory rate

Participant Measure Pre-course Post-course

1 Shuttle walk test 100m 210mHADS - anxiety 1 (non-case) 4 (non-case)HADS - Depression 1 (non-case) 2 (non-case)Minnesota Living with HF missing 40

2 Shuttle 300m 470mHADS Anxiety 8 (non-case) 8 (non-case)HADS Depression 2 (non-case) 4 (non-case)Minnesota 20 17

3 Shuttle 80m 150mHADS Anxiety 10 (borderline) 15 (caseness)HADS Depression 4 (non- case) 3 ( non case)Minnesota 37 31

4 Shuttle 10m / (died) HADS Anxiety 5 (non-case) /

HADS Depression 13 (caseness) /Minnesota 76 /

5 Shuttle 30m /HADS Anxiety 17 (caseness) /HADS Depression 10 (borderline) /Minnesota 61 /

6. Shuttle 20m /(died) HADS Anxiety 14 (caseness) /

HADS Depression 10 (caseness) /Minnesota 49

Goal achievementGoal achievementCommon goals:Common goals: To improve confidenceTo improve confidence To understand conditionTo understand condition To increase energy levelsTo increase energy levels To learn what I can do and how far to goTo learn what I can do and how far to go To take up a specific activityTo take up a specific activity To have a practical need metTo have a practical need metParticipants reported a good degree of Participants reported a good degree of

goal attainmentgoal attainment

Participant feedbackParticipant feedbackSemi-structured interviewSemi-structured interview

Altogether positiveAltogether positive Constructive:Constructive:

Programme offered at diagnosisProgramme offered at diagnosis Opportunity to attend at intervals in Opportunity to attend at intervals in

futurefuture Issue of prognosis, palliative care and Issue of prognosis, palliative care and

deathsdeaths Issue of maintenanceIssue of maintenance Issue of support for family membersIssue of support for family members

Staff feedbackStaff feedback Referrals –too few– Class 3 and 4: address Referrals –too few– Class 3 and 4: address

referralreferral Collaborative approach -individual goal Collaborative approach -individual goal

setting -home-based programme– worked wellsetting -home-based programme– worked well Develop rolling programme and flexible intervals Develop rolling programme and flexible intervals

for participants – address maintenance/community for participants – address maintenance/community linkslinks

Develop written informationDevelop written information Evaluation – Formal and sessional evaluation OK - Evaluation – Formal and sessional evaluation OK -

capture self-efficacy capture self-efficacy Confidence and experience of staff has Confidence and experience of staff has

developeddeveloped

Next stepsNext steps

Further developing as a rolling Further developing as a rolling programmeprogramme

Cardiologists and BHF heart failure Cardiologists and BHF heart failure nurses involved in recruitmentnurses involved in recruitment

Evolving links with community Evolving links with community services re. maintenanceservices re. maintenance

Continuing to evaluateContinuing to evaluate

Taking control of Heart Taking control of Heart FailureFailure

A community A community development projectdevelopment project

Taking control of Heart Taking control of Heart FailureFailure

A community development A community development projectproject

Based in inner west of Newcastle-Based in inner west of Newcastle-upon Tyneupon Tyne

Supported by grant from Health Supported by grant from Health Action Zone: partnership funding Action Zone: partnership funding for preventative programmesfor preventative programmes

Partnership of community and Partnership of community and health (PCT) providershealth (PCT) providers

Taking control of heart Taking control of heart failurefailureModelModel

Based on community development methods Based on community development methods and principals. Innovation-based.and principals. Innovation-based.

Objective: to empower people to take more Objective: to empower people to take more control of their lives – to add valuecontrol of their lives – to add value

Fundamentally a quality of life programme, Fundamentally a quality of life programme, not a disease based programmenot a disease based programme

Participants determine programme Participants determine programme structure and outcome evaluation (no structure and outcome evaluation (no physiological measures)physiological measures)

Taking control of heart Taking control of heart failurefailureProcessProcess

2 BHF funded HF nurses working with GPs 2 BHF funded HF nurses working with GPs and practice nurse IHD leads from 2 and practice nurse IHD leads from 2 practicespractices

32 people with class 2 heart failure identified32 people with class 2 heart failure identified Written invitation to participate – follow-up Written invitation to participate – follow-up

telephone calltelephone call BHF nurses visiting willing people at home to BHF nurses visiting willing people at home to

meet, provide information and discuss group.meet, provide information and discuss group. Invitation to group.Invitation to group.

Taking control of Heart Taking control of Heart FailureFailure

ProgrammeProgramme 2 closed groups2 closed groups Ten weekly sessionsTen weekly sessions Facilitated by community development Facilitated by community development

worker with experience in such worker with experience in such projects and group facilitationprojects and group facilitation

Content directed by groupContent directed by group Potential involvement of local cardiac Potential involvement of local cardiac

rehab team – pharmacist, psychologist, rehab team – pharmacist, psychologist, exercise specialists, nutritionistexercise specialists, nutritionist

Over to you…Over to you…