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The Bournemouth Heart Failure Service

Bournemouth Heart Failure Team
Rob Payne
Service Development Manager

Ramona Willis
Specialist Heart Failure Nurse

Amanda Whiting
Specialist Heart Failure Nurse

Stephen Collins
GP Special Interest

Adrian Rozkovec
Senior Cardiologist

E:heart.failure.team@rbch-tr.swest.nhs.uk

Chronic heart failure is an increasing burden in many countries. With more patients surviving myocardial infarction and a growing ageing population, the incidence and prevalence of chronic heart failure are set to increase. Estimates of the prevalence of heart failure range from 2% to 3% of the adult population, and this increases rapidly with age. It accounts for 5% of all acute medical admissions to hospital per annum. Admissions are often prolonged, and about one-third of patients are readmitted within 12 months of discharge. This creates a significant burden on local healthcare services in primary and secondary care, and consumes between 1% and 2% of healthcare expenditure in the UK.
Despite recent advances in drug therapies, chronic heart failure continues to be associated with high morbidity, high mortality rates and poorer than average quality-of-life scores.(4,5)
Bournemouth Primary Care Trust identified a need to improve heart failure care as part of its response to the National Service Framework for Coronary Heart Disease.(1) The PCT serves a population of 170,000, with a high number of elderly residents. Based on national data, we have estimated a local prevalence of 5,000 patients with heart failure and an incidence of 400-500 a year.

Learning from best practice
In order to develop a local service the project team visited Glasgow's "Heart Failure Service" (led by Professor McMurray). The team was keen to learn from this model of best practice and in particular from the work of Lynda Blue and colleagues.(6) The features of this programme were analysed in order to inform our own practice development. The key factors to the success of this programme were identified as:

  • Development of specialist nurse-led, home-based follow-up.
  • Optimisation of drug therapies.
  • Development of a programme of patient education and support.

Networking across other local heart failure services also helped us to prepare for potential problems and difficulties in setting up this service.

Developing the workforce
The role of the specialist heart failure nurse and GP assistant
The first phase of the service, developing the workforce, took place over six months. The team includes one whole- time-equivalent heart failure nurse specialist, one clinical session per week with a GP with a special interest, and the support of the consultant cardiologists. The team is employed by Bournemouth PCT and based in the cardiac department of the local district general hospital. A model of care based around the Glasgow service was developed and piloted. This has evolved into a "hybrid" service,(7) offering a combination of both domiciliary and clinic visits. A two-phase approach to the service was planned, with phase 1 focusing on patients being discharged from hospital or referred from cardiology outpatient clinics. Phase 2 involved the setting up of a "cardiac breathlessness clinic".
During phase 1, patients are visited at home within a week of discharge, and subsequent clinic or home visits and telephone contact continue according to patient need. The aim of phase 1 is to provide tailored and attentive healthcare by improving patient care management and follow-up. This involves the initiation and titration of heart failure treatment according to agreed guidelines, with education, advice and support for the patient and their family. The development of a "patient-held record" encourages the patient to be more knowledgeable in their own care, promoting effective communication between nurses, doctors, allied health professionals, the patient and their family.

Improving diagnostic assessment
The setting up of a cardiac breathlessness clinic
Primary care faces a problem in the reliable detection and diagnosis of heart failure. Recent therapeutic advances have made the early and accurate diagnosis of heart failure increasingly important. However, some patients with mild left ventricular dysfunction have little in the way of symptoms, and clinical signs can be absent or misleading. Even when the diagnosis seems straightforward, the cause of the heart failure may remain obscure. For this reason, primary care teams have sought open access to some of the investigations that help with the diagnosis.
Echocardiography is the most useful noninvasive test in the assessment of left ventricular function. However, no single investigation can be considered the gold standard for confirming the diagnosis. For this reason, we have decided to offer open access to a "cardiac breathlessness clinic" that pulls together several investigations. The clinic, which is located in the cardiac department at the Royal Bournemouth Hospital, is funded by Bournemouth PCT and staffed by heart failure nurses and a GP with a special interest. It provides a one-stop assessment combining clinical examination with all relevant blood tests, including near-patient testing for brain natriuretic peptide, chest X-ray, pulmonary function tests, 12 -lead electrocardiogram and echocardiography performed by a cardiac technician.
At the end of the assessment, the diagnosis and treatment plan will be immediately faxed to the patient's GP. Some patients with mild heart failure will be followed up within the community according to guidelines agreed by the cardiac department and the PCT. Some patients with more severe heart failure will be supported and managed by heart failure nurses. Other patients will need onward referral to cardiologists because the cause of the heart failure is not established and specialist assessment may be appropriate. This may include, for example, ischaemic and valvular heart disease, cardiomyopathies, and metabolic causes of heart failure. Similarly, there will need to be onward referral to chest physicians if the main cause of breathlessness is found to be respiratory. Easy access to a reliable diagnosis should help to focus resources and treatment on those patients most likely to benefit.

Understanding the patient's journey - process mapping and collaborative practice
The heart failure team are now working with the National Coronary Heart Disease Collaborative programme reviewing the patient care pathway and utilising small quality improvement cycles. The team has recently completed a process mapping exercise, and this has identified priorities for further service development.(8)
 
Investing for improvement - the future of heart failure services in Bournemouth
It is anticipated that the service will continue to grow, especially after the imminent launch of phase 2. It is difficult to predict future requirements, but if the Glasgow experience is anything to go by then more nurses will be needed to provide a full service to the 170,000 local population served.
It is not generally known that heart failure has a prognosis as bad as the average cancer. Our interventions slow the progress of heart failure and improve quality of life but rarely provide a cure. In recognition of the suffering that these patients experience in the terminal phases of their illness, it is hoped that there will shortly be government funding to set up palliative care services for people in the later stages of heart failure.
The Bournemouth Heart Failure Team would like to acknowledge the support of Val Smyth, Senior Project Manager, Dorset Strategic Health Authority (working on behalf of the National CHD Collaborative). The team are also grateful for the continued support of Bournemouth PCT and The Royal Bournemouth Hospital.

For further information on this project you can contact the team
E:heart.failure.team@rbch-tr.swest.nhs.uk
T:01202 704059

References

  1. Department of Health. National service framework for coronary heart disease. London: The Stationery Office; 2000.
  2. Department of Health. The NHS plan: a plan for investment a plan for reform. London: The Stationery Office; 2000.
  3. Department of Health. Liberating the talents: helping primary care trusts and nurses to deliver the NHS plan. London: The Stationery Office; 2002.
  4. McMurray JV, Clark AL. Heart failure diagnosis and management. London: Martin Dunitz; 2001.
  5. Davies MK, Hobbs FDR, Davis RC, et al. Prevalence of left ventricular systolic dysfunction and heart failure in Echocardiographic Heart of England Screening Study: a population based study. Lancet 2001;358:439-44.
  6. Stewart S, Blue L. Improving outcomes in chronic heart failure. A practical guide to specialist nurse intervention. London: BMJ Books; 2001.
  7. Stewart S, Blue L, Walker A, Morrison C, McMurray JJV. An economic analysis of specialist heart failure nurse management in the UK: can we afford not to implement it? Eur Heart J 2002;23:1369-78.
  8. Department of Health and NHS Modernisation Agency. Service improvement guide: heart failure. London: The Stationery Office; 2002. Available at URL: http://www.modern nhs.nhs.uk/CHD