Download Community Heart Failure Nurse Referral Form

Community Heart Failure Nurse Referral Form
All patients to have a diagnosis of Left Ventricular Systolic Dysfunction (See
accompanying Referral Guidelines)
To Access this Service: Fax Completed Form to 01293 600399
PATIENT DETAILS
GP DETAILS
Hospital / NHS No:
Name: Mr. / Mrs. / Ms.
Date:
Referring GP / Signature:
Address:
Address:
Post Code:
DOB:
Telephone:
Practice:
Post Code:
E-Mail:
Mobile
Home
Date of echo
Work
Echo result
ROUTINE
URGENT
Please tick below to indicate intervention required by heart failure nurse
Physical/psycho/social assessment
Education and lifestyle advice
Optimisation of medical therapy
Self-monitoring
Palliative care/ end of life management
Symptom control
Psychological support
Other (please specify)
Please tick below to indicate previous cardiac history, indicate date of diagnosis if known
Myocardial infarction or Angina
Known atrial Fibrillation
Angioplasty/Stent
Pacemaker/ Bivent-pacemaker
Coronary artery bypass graft
Implantable cardioverter defibrillator
Diabetes
Thyroid dysfunction
Hyperlipidaemia
Anaemia
Please tick below to indicate if patient has any of the below conditions, indicate date of diagnosis if known
Asthma
COPD
Hypertension
Acute/Chronic renal Disease
Please indicate aetiology of heart failure if known ____________________________________________
Please attach any further relevant information, e.g. Bloods, List of Medications
HEART FAILURE SPECIALIST NURSES REFERRAL CRITERIA
Any patient with confirmed diagnosis of Left Ventricular Systolic
Dysfunction (LVSD) CONFIRMED BY ECHOCARDIOGRAM
(Most recent Echocardiogram result attached to referral form/letter)
Inclusion Criteria
•
Main clinical problem of Acute/Chronic Heart Failure (LVSD) confirmed by
Echocardiography or other cardiac imaging modality confirming Left Ventricular
Systolic Dysfunction / significant abnormality (within the last 12 months)
•
New York Heart Association Classification Grading II-IV*
Class I: patients with no limitation of activities; they suffer no symptoms from
ordinary activities.
Class II: patients with slight, mild limitation of activity; they are comfortable with rest
or with mild exertion.
Class III: patients with marked limitation of activity; even during less-than-ordinary
activity, comfortable only at rest.
Class IV: patients who should be at complete rest, confined to bed or chair; any
physical activity brings on discomfort and symptoms occur at rest.
•
Under the care of a Crawley, Mid Sussex, Horsham and Chanctonbury Locality
GPs
*Those patients with NYHA Class I will be considered according to individual clinical
needs
Exclusion Criteria
•
No confirmed diagnosis of LVSD
•
Unwilling to receive support from the Community Heart Failure Team
•
inability to follow self-care advice and strategies without support
•
Symptoms of Heart Failure following recent Myocardial Infarction –these patients
will be followed up by Cardiac Rehabilitation and referred to Heart Failure Service if
required
•
Outside of service catchment area
Referrals should be made using HEART FAILURE Referral form or letter
The Heart Failure Specialist team will contact the patient directly to book an appointment
either at home or in a clinic setting.
Following initial assessment and completion of optimisation of HF medication. Once
stable, and on appropriate care plan, the patients will be discharged back to the referrer or
an appropriate alternative service i.e. Community Matron for further support.
A small number of patients may remain on the Heart Failure Specialist Nurses caseload if
it is considered appropriate to support self management and prevent further hospital
admissions.