Download Heart Failure Nursing Service and Rehabilitation.

GEORGE ELIOT HOSPITAL NHS TRUST
Heart Failure Nursing
Service and
Rehabilitation.
Operational Guide.
Author Emma West-Eggar
Heart Failure Clinical Nurse Specialist.
Version 1.0 21st December 2015.
This pathway has been developed as a guide to help Practitioners understand the Heart Failure
Nurse referral process for both the George Eliot Hospital Trust and NHS Warwickshire North CCG
General Practitioners.
Contents
Contents
Aims of the Service
Heart Failure Nurse Referral Criteria
Heart Failure Nurse Hospital Inpatient Pathway
Heart Failure Nurse Outpatient Pathway
Heart Failure Rehabilitation Phases
Discharge criteria
Appendix
Page
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Aims Of The Heart Failure Nursing Service
This operational guide is designed to provide Health Professionals with an overview of the
Heart Failure Nursing Service at George Eliot Hospital NHS Trust. The Heart Failure Nursing
Service aims at optimising care for patients with a diagnosis of Left Ventricular Systolic
Dysfunction with an Ejection Fraction of <45%. Education and self-management of patients
diagnosis and symptom control is essential using a variety of different written/verbal and
visual aids and is the primary aim of the service. Other services include Heart Failure
medication titration, an individually tailored education and exercise programme using the
Cardiac Rehabilitation model.
The Heart Failure Nurse Service is based at George Eliot Hospital and care is primarily
provided by a Heart Failure Clinical Nurse Specialist and a Consultant Cardiologist with a
Specialist interest in Heart Failure.
The Heart Failure Nursing Service operates Monday to Friday 8-4pm and can be accessed by
patients, relatives and any Healthcare Professional. The Heart Failure Clinical Nurse
Specialist has the opportunity to work closely with the Consultant Cardiologists and will
liaise with them if treatment plans are uncertain or complex.
The Heart Failure Team comprises of three Consultant Cardiologists and One Heart Failure
Clinical Nurse Specialist.
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Dr Asok Venkataraman – Consultant Cardiologist
Dr Suresh Krishnamoorthy – Consultant Cardiologist
Dr Babak Nazari – Consultant Emergency Medicine
Emma West-Eggar – Heart Failure Clinical Nurse Specialist
Heart Failure Nurse Office contact – 024 76 153841.
The Heart Failure Team Provide:
1)
2)
3)
4)
5)
Ward based consultations
Telephone support
Heart Failure Clinics including Heart Failure medicine titration
Education and training for patients, carers and other professional groups
Comprehensive exercise programme based at George Eliot Hospital depending on
suitability
6) Community exercise classes depending on suitability.
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Inclusion and exclusion inpatient/Outpatient criteria for the Heart Failure
Nursing Service
George Eliot Hospital NHS Trust.
Referral criteria for the Inpatient & Outpatient Heart Failure Nursing Service.
Inclusion Criteria.
1) Patients with LVSD <45% on echocardiogram either on current admission or
previous reports with any of the following:
a) Inoperable valve disease.
b) Patients diagnosed with Atrial Flutter/Fibrillation NOT suitable for any further
cardiac procedures.
c) Inoperable coronary artery disease.
d) Patients diagnosed with a Myocardial Infarction (MI) and NOT suitable for
revascularisation.
e) Any other Cardiac aetiology deemed appropriate for referral via Consultant
Cardiologist only.
Exclusion Criteria.
1) Confirmed Diastolic impairment without LVSD on echocardiogram.
2) Less than 6 weeks post Myocardial Infarction with LVSD. (6 week post MI
echocardiogram needed prior to HF referral). If LVSD <45% on 6 week
echocardiogram, refer to the Heart Failure Team.
3) Patients awaiting clinical intervention for Atrial Flutter/Fibrillation i.e. Cardioversion.
4) Operable valve disease.
5) Uncontrolled cardiac arrhythmia with a borderline/near normal EF or systolic
function.
6) Life limiting co-morbidity with a terminal prognosis (refer to Palliative Care Team).
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George Eliot Hospital Inpatient Heart Failure Nurse Pathway.
Patient referred prior to
discharge.
Ward refer patient to HFN
according to HFN
inclusion/exclusion criteria.
Please see HFN referral guidance.
HFN reviews patient, HF
medication introduced or
titration and education.
Cardiac Rehabilitation offered
depending on suitability
criteria. (Phase 1)
HFN requests cardiologist to
review/plan prior to discharge.
Patient discharged home.
HFN makes post discharge
phone call to check progress
(phase 2) Invite to education
programme (phase 3).
yes
HF plan implemented prior to
or during admission
Did the patient see Cardiologist
as an inpatient?
No
Patient requires a new HF
consultant follow up
appointment.
Patient attends outpatient
appointment for follow up with
HFN.
Review patients at HF MDT
Review in HFN clinic until
patient is suitable for Cardiac
Rehabilitation Programme or
dicharged from service.
yes
Are there any concerns about
the patient?
No
Patient to attend Cardiac
Rehabilitation exercise
programme depending on
suitability (phase 3).
Discharge patient to
Cardiologist/GP/Palliative
Care/Community Matrons.
Discharge to phase 4
community exercise
programme if suitable.
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George Eliot Hospital Outpatient Heart Failure Referral Pathway
Patient referred via GP with suspected signs and
symptoms of Heart Failure.
New or Existing diagnosis of Heart Failure?
NTpro BNP >400 or LVSD <45%
Existing Heart Failure patients with
confirmed diagnosis of Heart Failure
by Cardiologist and LVSD <45%.
Please refer via Heart Failure Nurse
referral form.
New patients suspected of having
Heart Failure.
Please refer using Diagnostic Heart
Failure Clinic referral form.
Does the patient need to be seen
within 2 weeks?
No
Yes
Seen by Consultant Cardiologist in Heart Failure
Clinic.
Patient to be referred to Hot Clinic,
Ambulatory Care Unit at GEH.
Confirmed LVSD
Ejection Fraction
<45%
Yes
Management plan by Cardiologist as
per NICE and ESC guidelines.
Cardiologist referral to HFN.
No
Cardiology clinic if
appropriate.
Seen by HFN in clinic
Clinical assessment, medication titration, education and
promotion of self-management. Invite to exercise programme if
suitable.
When agreed treatment plan completed,
plan to discharge patient as per NICE
guidelines 2010.
Discharge to Palliative Care Team, GP, Community Matrons or
continue to monitor in Cardiology Clinic as an outpatient.
HFN Discharge to phase 4 Community exercise programme if
suitable.
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Heart Failure Rehabilitation Phases.
Phase 1
Phase 1 Inpatient Heart Failure (HF) Rehabilitation includes:
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Inpatient review of HF symptoms, HF medication, HF aetiology and its
precipitating factors.
Teaching and education of HF and its physiological processes to both
patients and carers.
Empowering patients to self-manage symptoms of HF using the Heart
Failure Top Tips guidance. ( see appendix 1)
Offering a patient medication diary to all patients to encourage patient
participation in collating important information such as daily weights and
blood pressure readings.
Offering individually tailored verbal/written risk factor modification
information such as smoking, alcohol and blood pressure information in
line with current evidence based research.
Offer a follow up telephone call by the HF Nurse to assess symptoms on
discharge from hospital (phase 2) and to assess patient compliance with
medication.
Offer exercise rehabilitation classes if patient meets the British Association
for Cardiovascular Prevention and Rehabilitation (BACPR) criteria.
Provide contact details so that patients have access to Specialist HF advice
Monday-Friday 8-4pm.
Organise a date for follow up HF clinic with either Cardiologist or HF Nurse.
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Phase 2
Phase 2 Outpatient Heart Failure Rehabilitation includes:

Follow up phone call on discharge to include:
1) Clinical assessment of HF symptoms and to address any concerns the patient or carer
may have.
2) HF medication compliance.
3) Reiterate top tips for Heart Failure and reinforce the importance of patient
compliance.
4) To assess suitability for exercise rehabilitation.
5) To confirm Outpatient follow up with either Cardiologist or HF Nurse.
6) Assess identified risk factor modification and patient compliance.

Patient to attend Outpatient HF follow up clinic. All new patients not seen
as an Inpatient and meet the HF inclusion criteria will be followed up by the
HF Nurse as a new patient. All phase 1 information will be discussed during
this appointment. Medication titration and clinical examination will also be
included in the appointment.
Phase 3
Phase 3 Exercise and Education Rehabilitation includes:
Education Package

1)
2)
3)
4)
5)
All patients will be offered an education package based at George Eliot
Hospital and will include:
What is Heart Failure and the physiological process?
Heart Failure medications and the importance of patient compliance.
Exercise and Heart Failure.
Self-management of Heart Failure symptoms and risk factors.
Stress and relaxation.
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Exercise Package.

Patients deemed suitable for the HF exercise programme will receive the
following package:
1) Pre-exercise assessment with a Cardiac Physiotherapist to assess suitability and
fitness level for class participation.
2) Patients will be offered up to a maximum of 16 exercise sessions depending on
patients symptom control and wellness. The exercise programme will be
individually tailored to the patient and prescribed on a session by session basis
depending on progression.
N.B patients may be unable complete the full course to due to non-attendance
or relapse in condition. Patients may be invited to complete the full course if
possible.
3) Heart Failure symptoms and risk factor management will be reviewed prior to
discharge from the exercise sessions. Patients will be discharged from the
hospital service and offered the opportunity to participate in the phase 4
community exercise classes if suitable.
Phase 4.
Phase 4 Heart Failure Rehabilitation will include:


The opportunity for eligible patients to participate in a community exercise
package with “Fitter Futures”.
Patients to continue to be cared for by their own General Practitioner in
the community or any other Health Care Professional involved with the
patients care.
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Discharge Criteria
Patients can qualify for one or a combination of the following:
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Patients who are fully titrated on their HF medication or have reached
optimal treatment.
Exercise Rehabilitation has been completed and treatment plan has been
completed.
They have been referred to the Palliative Care Team, Community Matrons,
Virtual Ward or any other Specialist Teams to take over care of the patient.
Patient request.
Failure to attend Outpatient appointments.
Patients who are fully titrated or have reached optimal treatment and have
been discharged to the Community Phase 4 programme.
Please note: Referral back to the service should be via the GP or the Inpatient team, not
by the patient to the relevant Cardiologist.
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Apendix 1
Heart Failure Top Tips
1) Weigh yourself daily every morning after your first visit to the toilet. Please
ensure you are wearing minimal clothing before weighing yourself. Ensure that
the scales are placed on a flat hard surface and not carpet. Record each weight
in your Heart Failure Diary. It is important that you inform your GP, or Heart
Failure Nurse Specialist if your weight increases by 3-4 pounds (2kg) within 3-4
days.
2) Drink 7-8 mugs of fluid a day, approximately 3 and a half pints or 2 litres.
3) Seek advice from your GP or Heart Failure Nurse Specialist if you notice any of
the following symptoms:
 Waking at night with shortness of breath or coughing
 Weight increase of 3-4 pounds in 3-4 days
 You feel short of breath doing things that do not normally make you feel
breathless.
 New or increased ankle swelling or stomach bloating.
4) Ensure you have your annual Flu vaccination and a once only anti-pneumonia
vaccine.
5) Do not add salt to your diet and avoid foods that have a high salt content. Do
not use low Salt or Salt substitutes.
6) Please ensure that you take your Heart Failure Diary to ALL appointments and
ensure all information is kept up-to-date.
7) Please keep your diary up-to-date, including adding any new medication
prescribed.
8) Eat a healthy well balanced diet. Please seek advice from your Heart Failure
Nurse Specialist for more information.
9) Please ask your GP surgery for a Heart Failure booklet if you do not have one.
10) Never stop taking your medication unless you are told to do so by your Nurse or
Doctor. Do not run out of your tablets.
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GEORGE ELIOT HEART FAILURE NURSE REFERRAL FORM
Date Sent:……………………….….. Date Received:…………..…….…………..
Appointment:……………….……………
PATIENT DETAILS
GP DETAILS
Name....................................................................
Male/Female
DOB……………………………………..
NHS Number:
……………………………………………….
Address:………………………………………………
…………………………………………………………
………………………………………………………………
…………..
Post Code:…………………………………………………
Tel No:
(essential)…………………………………………….
Hospital/NHS
Number:………………………………………………
GP
Name………………………………………………………
…….
Practice Names:
…………………………………………………
Practice Address
stamp
Tel:…....................................................................
Fax:…………………………………………………………
………….
Investigation results to be provided with Referral
ECG (MUST be included with referral)
ECHO must be performed with LVSD & EF <45%
U&Es, Creatinine, FBC, Glucose, Liver Function tests, Thyroid function tests, Lipids.
Please Note: this from is for patients with a confirmed diagnosis of Heart Failure via Cardiologist with an Ejection
Fraction of <45%.
Patients with NEW signs and symptoms of Heart Failure should be referred via the Diagnostic Heart Failure Clinic
referral form.
1.
2.
3.
4.
5.
6.
7.
Symptom Review
Breathlessness
Orthoponea
Reduced Exercise
Tolerance
Peripheral Oedema
PND
Fatigue/Lethargy
Other please specify
Yes/No
Yes/No
Yes/No
1.
2.
3.
Past Medical History
Previous MI
Yes/No
History of Angina
Yes/No
Hypertension
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
4.
5.
6.
7.
Valvular Disease
Heart Murmur
Arrhythmias
Other please specify
Yes/No
Yes/No
Yes/No
Yes/No
Reason For Referral.
Current Medication (please attach printout if available)
Please Fax this referral to the number given below:
Telephone for enquiries: 024 76 153841
Fax Number for referral: 024 76 865704
Office use only: Appropriate referral – Yes/No
If inappropriate, state destination of final referral
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