BHF Heart Failure Specialist Nurses Outline • • • • • • • • What is the Heart Failure Service? Aims of the service Delivery of the service What do we do? Training and supervision Referrals and referral criteria Discharge from the service Case study What is the Heart Failure Service? The British Heart Foundation currently supports over 400 Heart Failure Specialist Nurses nationwide. “Heart Failure Specialist Nurses provide care and advice to heart failure patients in their own home, helping to keep them out of hospital and improving their quality of life.” What is the Heart failure Service? “They forge strong bonds with patients and their families, understanding their needs and concerns. They co-ordinate a shared care approach with other clinical and social services.” (BHF website www.bhf.org) Aims of the Heart Failure Service • Promote independence of educate patients so they have a good understanding of their disease and symptoms; • Promote self-management to enable patients to achieve optimum health and quality of life; • Optimise research-bases treatments/medicines to prevent reduce mortality and increase quality of life, and prevent unnecessary hospital admissions; Aims of the Heart Failure Service • Regular review and availability of heart failure nurse via telephone, thereby reducing GP visits; • Arrange appropriate palliative care to ensure comfort and symptom control at the end stages of the disease. Delivery of the Service • • • • 2.6 FTE Heart Failure Specialist Nurses Based at Oak Farm Clinic, Long Lane, Hillingdon Home visits 3 Community Clinics – North – Eastcote Health Centre – Central – Uxbridge Community Health Centre – South – HESA Community Health Centre, Hayes Nature of Service Provision • • • • Initial assessment and medication review; Symptom assessment; Education about disease, symptoms and treatments; Promotion of self management and advice about factors affecting symptoms; • Education about controlling symptoms; • Optimisation of research-based medicines, including necessary blood tests; • Regular review; Nature of Service Provision • Referral to other appropriate services e.g.: physiotherapy, Diabetes Specialist Nurses, District Nurses, Rapid Response, Social Services, Palliative Care Team, GP; • Health Promotion e.g.: smoking cessation; • Referral to Cardiac Rehabilitation; • Phone ‘helpline’. Guidelines Used • NICE Guidelines for Chronic heart failure: management of chronic heart failure in adults in primary and secondary care. (NICE Guidance CG108, August 2010) • ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012 (European Heart Journal (2012) 33, 1787-1847) Training and Clinical Supervision • Clinical Supervision monthly with Dr Simon Dubrey, Consultant Cardiologist at Hillingdon Hospital; • Consultant, registrar, and Heart Failure Specialist Nurse at Hillingdon Hospital; • Cardiology team and Heart Failure Specialist Nurse at Watford General Hospital and Northwick Park Hospital; • Monthly Heart Failure MDT meeting at Northwick Park Hospital with Dr Hugh Bethell and team; Training and Clinical Supervision • BHF Regional Conferences and Study Days; • Pan London Heart Failure Nurse meetings; • Heart Failure Course – Glasgow Caledonian University; • British Journal of Cardiac Nursing; • GP Practice MDT meetings. Referral Criteria • Diagnosis of left ventricular systolic dysfunction (LVSD) with objective evidence e.g.: echocardiogram, cardiac MRI; • Heart Failure is their main clinical problem; • Registered with a Hillingdon GP practice; • Willing to accept the added support of the service. Discharges • Patients may be discharged from the service if their medical therapy is optimised and their condition is stable, and they are able to self manage their condition; • Non-compliance/DNA; • Patient request; • GP request. Case Study • Mrs X 85 years old, lives alone, history of falls • Admitted to hospital under COTE with vomiting and weight loss, bilateral leg oedema to the knees. • Deranged LFTs and INR > 20 • Acute on chronic kidney injury • Echo: dilated LV with severe impairment of systolic function. EF 10% Medical history • • • • • • Hypertension CVA Hypothyroidism AF – on warfarin CKD Alcohol intake approximately 28 units/week In-hospital treatment INR corrected with Vitamin K and FFP IV fluids Antibiotics for cellulitis to left leg Liver screen serum blood test showed no apparent cause of deranged LFTs – probable congestion due to CCF Once U&E’s and LFT’s improved - started on treatment for heart failure including ACE inhibitor and diuretic Discharged home with care package Medications Ramipril 2.5mg od Bumetanide 2mg od Digoxin 125mcg od Levothyroxine Thiamine and Vitamin B compound Warfarin stopped and aspirin started + omeprazole Initial assessment BP 118/55, HR 65 (AF), Weight 79kg Lungs: wheezes throughout, no crackles. Patient is breathless on minimal exertion with cough Pitting oedema to knees – skin had broken down so dressings to these areas Initial blood test: eGFR 54, normal LFT’s Poor memory, mild dementia. Initial management Increase in diuretic dose Dosette box for medications Repeat blood test for U&E’s after 1 week Results Incontinence due to urinary frequency secondary to increase in diuretics - Referred to district nurse team for continence assessment and provision of pads. Good diuresis with increase in diuretics. Renal function remained stable. Patient reported breathing improved a lot. Chest clear and cough resolved. Oedema to legs resolved and wounds dry. Ongoing management Uptitration of ACE inhibitor in line with NICE Guidelines monitoring patient after each dose change including BP and U&E’s. Reduction in diuretic dose once oedema resolved Digoxin dose reduced due to bradycardia (no beta blocker) Any Questions?