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A sub-group of Lothian Coronary Heart Disease Managed Clinical Network
A sub-group of Lothian Coronary Heart Disease Managed Clinical Network
Normal Heart Failure
• 1 in 10 people aged over 75 years of age have heart failure• After hospitalisation - 25% mortality, 33% readmitted within 1 year• Commonest cause in Scotland is coronary heart disease
Chronic Heart Failure
Chronic Heart Failure
Exhausted and fatiguedBreathless
Chest pains/palpitationsAnkle swelling
Unable to do every-day tasksDepressed
Cycles of Heart Failure Care
HomeHome
GP surgeryGP surgery
OP clinicOP clinic
HospitalisationHospitalisation
Typical Heart Failure Patient 2005SIGN Guidelines 35, 1999
Diagnosis and treatment of heart failure due to left ventricular systolic dysfunction
Treatments InvestigationsDiuretic FBC, U&E, Glucose ACE inhibitor ECG, Echocardiogram
Digoxin Digoxin level in the bloodBeta BlockerStatin
Warfarin
Flu/pneumovax immunisationSpironolactone
CholesterolINR
AII antagonist
Caring for a patient with Heart Failure
Medical Considerations:
• Tablets & medications
• Regular blood tests
• Other medical conditions
• Immunization
• Close outpatient monitoring for early features of deterioration
Lifestyle Modifications:Lifestyle Modifications:
• Weight monitoring/reductionWeight monitoring/reduction
• Discontinue smokingDiscontinue smoking
• Avoid alcohol Avoid alcohol
• ExerciseExercise
• Salt restrictionSalt restriction
Social & Palliative issues:Social & Palliative issues:
• Social needs of patientSocial needs of patient
• Family/carer supportFamily/carer support
• Hospice/end of life careHospice/end of life care
Chronic Heart Failure
Primary Care TeamGPPractice NurseHealth VisitorPharmacistSocial worker
Hospital TeamPhysician - GeneralistSpecialist (Cardiology)Specialist (CHF)Cardiology/Rehab NursePharmacist
Primary careSurgery visitsPractice nurseHome visits
HospitalAdmissionsOP clinic
Primary Care TeamGPPractice NurseHealth VisitorPharmacistSocial workerPalliative care team
Secondary Care TeamPhysician GeneralistSpecialist (Cardiology)Specialist (CHF)Cardiology/Rehab NursePharmacist
Primary careSurgery visitsPractice nurseHome visits
HospitalAdmissionsOP clinic
GPPractice NurseHealth VisitorPharmacistSocial workerPalliative care team
Physician GeneralistSpecialist (Cardiology)Specialist (CHF)Cardiology/Rehab NursePharmacist
HEART FAILURE TEAM
Lothian Managed Clinical Network (Heart Failure)
General practitioner
SpecialistHF nurses
CardiologistSpecialist/EP
Geriatrician/care of the elderly elderly
Pharmacist
DietitianPalliative Care
team
Social Services
District nurse
Rehabilitation
Volunteer support workers
Patient
Guidelines - evidence based, local
needs Web-based decision support program
Beta blocker/ACE inhibitor up-titration
clinics
Direct access echocardiography
Brain Natriuretic Peptide & ECG
Cardiology OP clinics
Data collection & audit
Research
Palliative Care referral guidelines
Education program
Specialist Heart Failure nurses
Volunteer support program - mentor, non-
medical needs
Healthcare professional
Support for the healthcare professional
0102030405060708090
100
ACE inhib
itors
Beta b
locke
rs
Diure
tics
Spiron
olacto
ne
Digox
in
% p
atie
nts
on
th
is d
rug
Normal Care (n=594)
CHF nurse (n=257)
Multidisciplinary Team Effect on use of Heart Failure medications
April 2005
April 2003
-80
-60
-40
-20
0
20
40
60
80
%
Multidisciplinary careEffects on admissions and time spent in hospital
Bed days saved = 582 in 6 months
6 months before and after enrolment in the multidisciplinary CHF service
46% 70% 52%
66%All cause
admissionsHeart Failure
admissionsDays spentIn hospital
Days betweenHospital admissions
Multidisciplinary careChest, Heart & Stroke, Scotland
•10 trained lay-volunteers
•Visiting people with heart failurein their own home
•Providing befriending service
Involving Patients and their FamiliesChest, Heart & Stroke, ScotlandStudy Group on Heart Failure Awareness and Perception in Europe
Heart Failure Patient Forum
First meeting on 1st June 2005
61 patients and carers attended
“..good to know there are others in the same boat…”
“…I felt someone was listening..”
Newsletter for patients and carers
Multidisciplinary approach to heart failure management
• Deliver high quality evidence-based care
• Reduce hospitalisation
• Improve symptoms
• Improve quality of life
• Involve patients and their families
Multidisciplinary Team
GP’s
Dr Carl Bickler
Dr Geoff Dobson
Dr Scott Murray
Dr Bob Finnie
Community Nurses
Mary Stewart
Nancy Kirkland
Pharmacists
Fiona Reid
Fiona Murphy
Managers
Lyn MacDonald
Anne Ovens
Heart Failure Nurses
Maureen Smith
Janet Reid
Sinead McKee
Maureen O’Donnell
Diane Yellowlees
Andrea Ness
Susan Brown
Patient representatives
Linda Garcia
Palliative Care Physicians
Kirsty Boyd
Web programmers
Mark Hartswood
Database Manager
Colin Ferrington
Researchers
Rebekah Pratt
Loraine Francis
Care of the Elderly Physicians
Patricia Cantley
Chest, Heart & Stroke, Scotland
Campbell Chalmers
Louise Peardon
Rae Goode
Cardiologists
Andrew Flapan
Ashok Jacob
Martin Denvir
Catherine Labinjoh
Steve Leslie
John Lemaitre
