Transcript A Modern Heart Failure Service - NHS Improvement

How to make evidence based
practice happen
- Identifying the local priorities
Dr David Walker
NHS Improvement
National Clinical Lead for Heart Failure
The role of NHS Improvement
• Started out as CHD collaborative to assist with
implementation of NSF
• 10 years experience of working with
primary/secondary/tertiary care to improve local
HF services
• Publications on individual projects,
commissioning, end of life care etc.
• Recently a more proactive approach, contacting
Trusts with long LOS and high readmission rates
What makes a good HF service?
• Systems for early accurate diagnosis
– RAHFC
– Availability of BNP to streamline referrals
– Access to echocardiography
• Systems to identify patients in hospital and
concentrate them where there is expertise
– Access to HF nurse (can “pull” patients to
cardiac ward, where there are appropriate
protocols in place)
– More rapid echocardiography on in-patients
What makes a good HF service?
• Seamless service
– Liaison between in patient HF nurses and
community HF nurses to allow prompt
discharge
– MDT meetings to discuss patients across
primary and secondary care – to allow
adjusting of medication to prevent
unnecessary admissions (regular interaction
between medical team, hospital HF nurse(s)
and community HF nurse(s) is critical)
– Palliative care involvement
• Above all, a local clinical champion
“NHS 2010-2015: from good to great,
preventative, people centred, productive”
Heart Failure:• Early, accurate diagnosis, including the use of
diagnostics such as BNP and echo
• Optimising treatment through medication,
rehabilitation and devices if necessary
• Use of MDTs to provide more seamless care
• Care co-ordinators to help patients and carers
navigate through complex pathways
• End of Life Care
“Early accurate diagnosis”
• Can be in or out of hospital
• Rapid Access Heart Failure Clinics
– echocardiography on the day
– BNP reduces referrals (eg by 30% in Plymouth)
– Management plan provided on the day
• Open access echocardiography
• BNP in MAU improves speed of diagnosis and
access to echo (eg increased echo confirmation of
diagnosis from 22-75% in Hemel, with reduced
readmissions)
• Ensure patients are on HF registers
BNP on admission reduces
readmissions (W Herts)
readmissions
60
50
40
2008-2009
30
2009-2010
20
10
0
readmissions
<30day readmissions
“Optimising treatment through
medication, rehabilitation and devices if
necessary”
• Systems in place to ensure the optimisation of
medication
– Hospital HF nurses (in some areas)
– Community HF Nurses
– GP Practices (incl. practice nurses)
– e.g. 16% HF admissions avoidable with
correct up-titration of ACE-I and b blockers
seen in Rotherham (pharmacist led)
• Patient education facilitates self-management
Local Enhanced Scheme for GPs
- Manchester
Number of admissions for heart failure per four quarter period
vs. % LES introduced
1.20
100%
1.00
0.80
0.60
50%
0.40
25%
0.20
0.00
0%
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
05/06 to 05/06 to 05/06 to 05/06 to 06/07 to 06/07 to 06/07 to 06/07 to 07/08 to 07/08 to 07/08 to 07/08 to 08/09 to 08/09 to
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
05/06
06/07
06/07
06/07
06/07
07/08
07/08
07/08
07/08
08/09
08/09
08/09
08/09
09/10
period
% LES introduced
readmissions per 1000 pop
75%
Pre LES
Training
LES
LES
Non LES
Optimising treatment: Rehab in HF
• Variable evidence base
• AHA Scientific Statement: Exercise and Heart
Failure 2003
– Improved exercise tolerance
– Improved endothelial function
– Reduced catecholamines
– Trials too small to show mortality benefit
• Efficacy and Safety of Exercise Training in Patients
With Chronic Heart Failure: HF-ACTION RCT (2009)
– 11% reduction in death/hospitalisation
– 9% reduction in CV death/hospitalisation
– 15% reduction in CV death/HF hospitalisation
Optimising treatment: Rehab in HF
• But the bad news is:– Very variable service across UK
– Many rehab services have struggled for staff
due to underfunding – and have not seen HF
as part of their core service
• Cardiac Rehab in general is a DH priority
– “Unfinished business” from the NSF
Optimising treatment: Devices
CRT rates: –
improving but still patchy
may be a surrogate for a good HF service
Concept of integrated care is not a
new one…
Integrated care requires “methods and
organisations to provide the most costeffective and caring services to those with
the greatest health needs and to ensure
continuity of care and co-ordination
between different services”
Integrated Care – Development Issues from an International Perspective:
Models and Issues. Healthcare Review , 2(5) March,1998
MDT working in Heart failure
•
•
•
•
Facilitates co-ordination of care
Promotes professional collaboration
Improves patient satisfaction
Reduces resource use and costs?
– So far appears cost neutral but with improved
quality
Multi-disciplinary Team members
•
•
•
•
•
•
•
•
•
Consultant (Heart Failure specialist)
GP/GPwSI
Community HF Nurses
Hospital based HF Nurses
Practice Nurses
Pharmacists
Rehab Team
Palliative Care
Improvement team
MDT: Integrated care
• The exact composition of the team in any area
doesn’t matter
• The key is to deliver a seamless service across
primary and secondary care (+ tertiary care)
• A local team leader is essential
– usually a consultant
• Communication is the key
– Case management by healthcare professional
– Regular case conferences to discuss problems
– Carer engagement
– Frequent transfer of information across
primary and secondary care interface
Hastings: Service Milestones
Pre-1999
1999
2000
2001
2003
2004
2009
No formal heart failure service
Part time nurse involvement
Local guidelines on heart failure management
Full time hospital-based nurse appointed
Nurse-led heart failure clinic started
Weekly multi-disciplinary heart failure team
meeting
Rapid access heart failure clinic introduced
Community (BHF) nurses appointed
Full integrated service
Heart failure ward rounds
HF patients concentrated on 2 wards
Hastings v UK HF admissions
Trends in annual heart failure admissions
1998 = 100%
130%
125%
120%
115%
110%
105%
HES
100%
Conquest
95%
90%
85%
80%
75%
70%
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Independent analysis by David Cunningham, CCAD
Mortality
In-patient deaths after emergency heart failure admissions
Conquest Hospital
100
y = -4.2955x + 93.886
R = -0.744
90
80
70
60
50
40
30
20
10
0
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
CRT implantation rising from 2004
CRT Implant Rate in Hastings and Rother
comparison with England average and national target
160
140
120
Conquest
England
100
Target
80
60
40
20
0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
No improvement in LOS
Length of Stay - All Admissions
Conquest Hospital vs national (HES) data
19
18
17
16
15
Conquest
HES
14
13
12
11
10
1996
1998
2000
2002
2004
2006
2008
2010
Hastings 5th oldest PCT in England – may make it harder to discharge people
Reduced Length of Stay - Essex
Length of Stay (LoS) by monthly discharges - Primary diagnosis of HF
20.00
18.00
16.00
12.00
10.00
8.00
6.00
4.00
2.00
Month
Avg LoS Days
Med LoS Days
09
Ap
r-
Fe
b09
ec
-0
8
D
ct
-0
8
O
Au
g08
Ju
n08
08
Ap
r-
Fe
b08
ec
-0
7
D
ct
-0
7
O
Au
g07
Ju
n07
07
0.00
Ap
r-
LoS in Days
14.00
LOS / Readmission Rates
20
16.00%
18
14.00%
16
12.00%
14
10.00%
Days
12
10
8.00%
8
6.00%
6
4.00%
4
2.00%
2
0
0.00%
Trust Code
Trust LOS
National Avg LOS
Trust Readmission Rate
National Avg Readmission Rate
MDT and “care co-ordinators”
• MDT can work well
• Fewer patients slip through the net
• Concentrating patients where the expertise exists to look
after them allows more streamlined care
• Community HF nurses make ideal care co-ordinators for
heart failure patients
– Provide support in patients homes
– Telephone advice when required
– In regular touch with hospital team providing link between
primary and secondary care
– Making community services robust 24/7 will be a challenge
Heart Failure Disease Trajectory
End of Life Care in HF
•
•
•
•
•
•
•
Open communication
Symptom control
Social and spiritual support
Advance care planning
Preferred place of care
Revision of drugs / devices
Carer support / bereavement care
Doctors confidence in delivering end of
life care
Nov 2008
Do you know how you are doing?
• Composition of service in your area
– Are all the appropriate staff in place?
– Are there any artificial barriers between
primary and secondary care?
– Do you have MDT meetings?
– Is there any access to rehab?
– Is there any interaction with palliative care?
Do you know how you are doing?
• Is the service well organised?
– System for rapid diagnosis of out patients?
• Community BNP, RAHFC, open access echo?
– How are in-patients with HF identified and
managed
• BNP, early IP echo, protocols for IV diuretics,
nursed in appropriate area, do patients see a
cardiologist/HF specialist?
– Discharge planning? (and summary)
– Follow up protocols, monitoring etc?
Do you know how you are doing?
• Do you know your audit data?
– What is the local prevalence from GP
databases? – is it realistic?
– National HF audit
– HES data – LOS, readmission rate,
mortality?
– Do you audit other aspects of your local
service?
Why is this work so important?
What about the human costs…?