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MCLG Term 2 Heart Failure Summary of Learning
This is a summary of the main shared learning within all the Multi-professional Collaborative
Learning Groups across Barnet for Heart Failure
1. Differential diagnosis this case raised
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Heart Failure
Worsening COPD
Chest Infection
Atrial Flutter/PAF/AF
Lung Cancer
Angina with Ischaemia
Anaemia
Chronic Depression
Diabetic Cardiomyopathy
Silent MI
Iatrogenic cause
Renal Failure
TB
Steps to differentiate between the above possibilities:
Investigations:
 Blood Tests: FBC, TFT, U+E, LFT, Haematinic Screen
 Radiology: CXR
 Cardiology Tests: ECG, 24h ECG, Echo
 Respiratory Tests: Spirometry, Sputum Culture
 Urine: Urinalysis to exclude Haematuria/Proteinuria
2. Next steps to help with Mr Shah, role-specific
 GP
o Initiate a Beta-blocker e.g. Bisoprolol. Clinicians were happy to initiate a
cardio-selective B-blocker, starting a 2.5mg once daily and titrating up
o Initiate an ACE-I: starting at a low dose, e.g. Ramipril 2.5mg once daily and
titrating up with U+E check at 2w and then regularly when dose titrated
o Initiate Furosemide 20-40mg once daily to treat symptoms
o Pioglitazone contra-indicated in Heart Failure so should be stopped.
Suggestions for alternatives included a Gliptin, e.g Sitagliptin, or possibly
metformin(can go up to 3g/day of the immediate release according to the
SPC but BNF slightly different in its advice ‘usual max 2g/day)
o As Amlodipine increases the level of Simvastatin and only maximum 20mg
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Simvastatin can be co-prescribed and as Cholesterol and TG high could switch
to Atorvastatin 10mg or 20mg
Seretide not licensed for COPD – suggest a review and possible switch to
DuoResp
Refer to Out-Patient Cardiology for further management and investigation of
the underlying cause for the Heart Failure
GP to encourage patient to manage his health. To explore why Mr Shah is
reluctant to engage with social services. Important to discuss why new
medications are being started and old medications being stopped and
alternatives prescribed – this will help compliance
GP to refer to appropriate health care professionals as below
 Practice Nurse
o To review patient’s COPD and to check inhaler technique
 Pharmacist
Services offered by Community Pharmacists to help patients with regards to his
medicine management/support/compliance:
o New Medicines Service(NMS)
 The service provides support for people with long-term conditions
newly prescribed a medicine to help medicines adherence; it is
initially focused on particular patient groups and conditions.
 See link below for further information:
http://psnc.org.uk/services-commissioning/advanced-services/nms/
o Medicine Use Review (MUR)
 carried out by community pharmacist – an overview of what
medications the patient is taking, but patient needs to have been
coming to the same pharmacist for >3months. Pharmacists discuss
compliance/adr’s of medications, when and how to take medications,
check no interactions. A useful service, but no BP or blood tests done,
so potentially patients will still need a review of things like
Hypertension medications/Cholesterol so duplication of work within
General Practice and Community Pharmacies
 see link below for further information:
http://psnc.org.uk/services-commissioning/advanced-services/murs/
o WWHAM – these are the questions asked by the pharmacist when patients
come to the pharmacy requesting otc medications:
 Who the medicine is for?
 What is the problem?
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How long has it been a problem, i.e. duration of symptoms?
Action that has been taken to date
What other Medicines, if any, is the patient taking?
 Social Worker
o GP’s can refer the patient and moreover, his wife for an Enablement package:
 Enablement Package - available for up to 6 weeks via Social Care
Direct, which is free but need to specify a reason for requiring this
service. It can be available to individual patients again(for a second
time) but again there needs to be a specific outcome as a result of the
enablement package, e.g. a patient who has broken their hip needs
social care input until mobility improves so this can be given through
an enablement package. Can access through Social Care Direct on 020
8359 5000. To be aware that this package of care can be withdrawn
early if no progress is made towards more independence or the goals
set out.
o Paying for Social Care – assessment takes into account finances and needs.
 Finances: at present threshold is £23,500 and if you have more than
this in savings then you will have to self-pay. Social services would
expect one to release funds from fixed assets such as a patient’s
home to fund any social care. If qualify for funding can either have
services contracted on your behalf by social services or take the
money and arrange social services independently. Useful website
called www.mycaremyhome.co.uk - this is a limited company who
specialise in helping people find the appropriate care(either at home
or private placement) and is recommended by social services
 Needs: Needs are related to tasks e.g. assistance with
washing/dressing/medication prompt and carers are given enough time
to carry out these tasks. There is no capacity to have a ‘sitter’ (unless selffunding). A social worker carries out the initial assessment and then the
care agency, once hired either independently or via social services, then
perform their own assessment, including assessment of risk. Carers are
now entitled to an assessment of their needs.
3. Resources available to help
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Prodigy website – http://prodigy.clarity.co.uk/
Prodigy topics are the clinical content for the Clinical Knowledge Summaries (CKS)
service for the National Institute for Health and Care Excellence (NICE). It is a website
aimed at healthcare professionals working in primary and first contact care and
include 341 topics consisting of 1000 clinical presentations or patient scenarios. The
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clinical content is continually monitored and reviewed, and new topics introduced
each year, that support the implementation of UK national policies and guidance,
address the information needs of the target audience and are relevant to primary
healthcare professionals.
Link for Heart Failure on the Prodigy website – this contains background information,
several scenarios to work through:
http://cks.nice.org.uk/heart-failure-chronic
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Heart Failure risk calculator: http://www.heartfailurerisk.org/
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Heart Failure Nurse: Abigail Matsika 07903 848612
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Community COPD Input / Pulmonary Rehabilitation Nurse: can either e-mail
[email protected] or phone: 07943 828371 or see Barnet Intranet Link:
http://nww.barnet.nhs.uk/referrals/services/Pages/COPD.aspx
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Cardiologist email advice/guidance service (within two working days):
For advice and/or guidance it is essential to include all the information, if possible in
bullet points so that the consultant can give the right advice and you can be
contacted by them if necessary to seek clarification. Any clinical queries concerning
patients can be emailed to the following address for a consultant response within
two working days: [email protected]
E-mail from an nhs.net account and the following in your e-mail:
o Patient’s NHS number in the title of the email
o Your name, role and contact details
o The patients details (age, sex, and the RFL patient number if known), relevant
clinical history including results of recent diagnostic tests within the relevant
specialty
o The clinical question(s) requiring an answer
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Barnet Intranet Link for Cardiology: Link below has lots of information about referral
pathways for investigations, community cardiology clinic referral forms, contact
numbers and e-mails for guidance and advice
http://nww.barnet.nhs.uk/referrals/services/pages/cardiology-south.aspx
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Heart Failure Clinic including a nurse led clinic. Urgent clinic slots potentially
available via on-call Cardiology Registrar at Barnet Hospital
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CCG Community Cardiology Service Flow Chart (see attached document)
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TREAT/Ambulatory Care at Barnet Hospital – may well just be my problem as
Harrow GP (& I know a flow chart has already been circulated) but I still don’t know
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the difference btw TREAT/HOT and PACES!!! – do you think worth spelling them out
Can contact them by ringing 0208 216 5765. The function of this HOT clinic is to
assess and address patient’s needs rapidly within a multidisciplinary structure. The
aim is to link with any and all community teams (GPs, A&E, PACE, urgent care centres
etc) to ensure appropriate care provision is in place to enable a patient’s safe return
home without the need for hospital admission. There will be 6 slots per day, 5 days a
week. Link below for RFH TREAT contact details and full details of resources and
times, conditions and access:
http://nww.barnet.nhs.uk/Docs/Referral%20Forms/HOT_clinic_criteria_8th_March_
201311.doc
4. Resources available to help manage patients with diagnosis of Heart
Failure at home and also with End of Life Care
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Patient and family oriented information on heart failure:
https://www.bhf.org.uk/heart-health/conditions/heart-failure
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Anticipatory Care Medication and Prescribing
o Anticipatory prescribing is designed to ensure that there is a supply of drugs
in the patient’s home, combined with the apparatus needed to administer
them, with the intention that they are available to an attending clinician for
use after an appropriate clinical assessment. Soon GPs will be able to issue a
script for the 4 most commonly used drugs in end of life by entering a code
on Emis.
o Fairview Pharmacy, Finchley Memorial Hospital, Granville Road, London, N12
OJE – 020 8346 0707 – stocks Anticipatory medicines
o There are some challenges around Anticipatory Care Medication – see link
below for further information on this topic:
http://bma.org.uk/practical-support-at-work/gp-practices/serviceprovision/prescribing/focus-on-anticipatory-prescribing-for-end-of-life-care
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Macmillan Cancer Support - have PILs that can be downloaded for family and
patients:
http://be.macmillan.org.uk/be/p-22060-heart-health-and-cancer-treatment.aspx
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North London Hospice Palliative Care Support Services – can be mobilised within 2h
http://www.northlondonhospice.org/our-services/community-specialist-palliativecare-service/
Advocacy in Barnet – can provide an advocate who will complete an Advanced Care
Plan – they will visit patients in their own homes and in hospital and are fully trained
with knowledge that incorporates a wide range of advice:
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http://www.advocacyinbarnet.org.uk/
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