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Public Health Wales
1000 Lives + Chronic Heart Failure H2G
Primary Care
Chronic Heart Failure
(Left Ventricular
Systolic Dysfunction)
How to Guide
This guide has been produced to enable GP Practices and their teams to successfully implement
a series of care bundles in a timely manner and apply the Model for Improvement when
monitoring patients with suspected /confirmed Heart Failure.
There is a summarised version of this document which can be accessed at
PCQIS site http://howis.wales.nhs.uk/sitesplus/888/page/34030
Final
December 2012
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Acknowledgements
This guide has been produced by Primary Care Quality & Information Service (PCQIS) with
input from Dr Paul Myres, Debbie Davies, Dr Graham Thomas, Dr Richard Lawrance, Louise
Howard Baker, and Breeda Worthington (NLIAH) and the All Wales Cardiac Network Groups.
We would like to thank Health Boards and GP Practices in Wales and their teams for their
endeavours in implementing these interventions and also feeding back lessons and
experiences gained.
PCQIS and 1000 Lives Plus have successfully engaged with a number of experts in
Primary and Secondary care to produce this guide for Chronic Heart Failure. It has been
developed by specialist practitioners in Wales and the content based on evidence and
recommendations from NICE1, National Heart Failure Audit 2012 2, European Society of
Cardiology (ESC) guidelines for the diagnosis and treatment of acute and chronic heart
failure 20123, Cardiac Disease NSF for Wales4, PCQIS chronic heart failure toolkit5, Welsh
Medicines Resource Centre 6, European Society of Cardiology (ESC) 2008 Acute and
Chronic Heart Failure Clinical Practice Guidelines 7, Prodigy (formerly CKS) Chronic Heart
Failure guidelines 2010.8
We wish to thank and acknowledge the Institute for Healthcare Improvement (IHI) and the
Health Foundation for their support and contribution to 1000 Lives Plus
Date of publication and Proposed Review Date
This guide was published in December 2012 and will be reviewed in 2014. The latest
version will be available online on the programme’s website:
www.1000livesplus.wales.nhs.uk
Purpose of the Guide
The aim of this guide is to assist practices to review the quality of the service that they
provide to patients with suspected /confirmed Chronic Heart Failure.
It has been produced to enable GP Practices and their teams to successfully implement a
series of care bundles in a timely manner, and to improve the safety and quality of care
that their patients receive.
This ‘How to Guide’ must be read in conjunction with the following:
 Leading the Way to Safety and Quality Improvement
http://www.wales.nhs.uk/sites3/Documents/781/How%20to%20%281%29%20Lea
ding%20the%20Way%20%28Feb%202011%29%20Web.pdf
 How to Improve
The Quality Improvement Guide
Further information is also available to support you in your improvement work:
PCQIS site http://howis.wales.nhs.uk/sitesplus/888/page/34030
Deanery site
The new GP Appraisal & CPD website can be found here;
https://nhswalesappraisal.org.uk/
1000 Lives Plus 14 Cathedral Road, Cardiff CF11 9LJ | Tel: (029) 2022 7744
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Email: [email protected] | Web: www.1000livesplus.wales.nhs.uk
Twitter: www.twitter.com/1000livesplus
Foreword
All general medical practices will have patients with heart failure. Research has shown what
treatments improve quality of life and prolong life. Guidelines have been published to help
us deliver those treatments. However, we know that not all eligible patients are receiving
those treatments.
This guide, and its associated collaborative programme, aims to put that right by
encouraging and supporting primary medical care teams to examine the care they provide,
reflect on their services and try different approaches as necessary to improve.
The 1000 lives plus approach requires practices to design their processes to meet the needs
of their patients in ways appropriate to their circumstances by considering their own data
and comparing it with what they would wish it to be. It encourages practices to compare
themselves with others and learn from what others have done. Similarly it asks
participating practices to share their learning with others.
This is the first “How to Guide” specifically aimed at general medical practice. It is
concerned with an area of disease where we know collectively we can do better. It relies on
us to work constructively with our secondary care colleagues. It puts responsibility on all of
us in the general medical practice team to improve.
Paul Myres
Primary Medical Care Lead
1000 lives plus
Chair
Royal College of GPs Wales
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Making Patient Safety a priority
The 1000 Lives Campaign has shown that by working as a collaboration it encompasses not
only health services within secondary care organisations but also community based
alliances from health clinics and associated general practices who together support mutual
aims: the avoidance of unnecessary harm, improvement to services that are delivered and
an evidence-informed approach with patient safety as a priority.
The enthusiasm, energy and commitment of teams to improve patient safety by following a
systematic, evidence-based approach has resulted in many examples of demonstrable
safety improvement.
However, as we move forward with 1000 Lives Plus, we know that harm and error continue
to be a fact of life and that this applies to health systems across the world. We know that
much of this harm is avoidable and that we can make changes that reduce the risk of harm
occurring. Safety problems can’t be solved by using the same kind of thinking that created
them in the first place.
In General Practice the field of patient safety has tended to focus on adverse events and on
the development of specific solutions aimed at preventing these events. We know that
much of the harm is avoidable and that changes in practice and procedures can reduce the
risk of harm occurring. Developing a positive safety culture depends on communication
between all members of the health care organisation. The health care organisation needs
to:

Acknowledge the scope of the problem and make a clear commitment to change.

Recognise that most harm is caused by bad systems and not bad people.

Acknowledge that improving patient safety and outcomes requires everyone on the
health care team to work in partnership with one another, patients and families.
The national vision for NHS Wales is to create a world-class service by 2015; one which
minimises avoidable death, pain, delays, helplessness and waste. The guide is grounded in
practical experience and builds on learning from organisations across Wales. The National
Patient Safety Agency Seven Steps to patient safety in general practice guide describes the
key steps for a general practice to take to avoid harming the patients they care for.
http://www.nrls.npsa.nhs.uk/resources/collections/seven-steps-to-patientsafety/?entryid45=59804
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Contents Page
Introduction
6
Driver Diagram
9
Getting Started
10
Drivers and Interventions
11
How do we introduce changes to processes?
16
How do we measure for Improvement?
19
References
24
Appendices
Setting up your team
25
The Model for Improvement
27
How to test change
28
Process Measures with descriptors
29
READ codes
32
Helpful Resources
38
Glossary
46
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Introduction
Aim: To Reduce Morbidity for patients with Chronic Heart Failure (CHF) (Left
Ventricular Systolic Dysfunction) (LVSD)
Heart failure is increasing in prevalence as a chronic condition and it presents significant
challenges to individuals, their families and the healthcare system.
Currently 900,000 people in the UK have heart failure. The incidence and prevalence of
heart failure rises steeply with age, the average age of first diagnosis is 76 years. Heart
failure has a poor prognosis, almost 40% of patients diagnosed die within a year.1,2
Prevalence of recorded heart failure mostly falls short of predicted levels which could
indicate that there is a largely unseen demand for investigations, clinical assessment and
care. There are several types of heart failure2. The strongest evidence base at present is
for Left Ventricular Dysfunction (LVSD).
Whilst substantial progress has been made over the last few years, there is considerable
national variation8:



Variation between different groups of patients.
Variation in the confirmation of a diagnosis.
Variation in access to evidence-based treatment and heart failure specialist staff.
The impact of delivering evidence-based care
One of the main objectives of managing patients with CHF is to introduce appropriate
drug therapy, including ACE inhibitors and beta-blockers, ideally titrating doses up to the
optimal target doses used in the large randomised controlled trials. There is good
evidence that this goal can be achieved in the majority of patients if a determined and
concerted effort is made in hospital, at outpatient clinics and in the community.1
Over 50 clinical trials have shown that, in patients with reduced left ventricular systolic
function, ACE inhibitors, angiotensin receptor blockers (ARBs), and beta-blockers reduce
symptoms, readmission rates, and mortality. Studies report that the use of ACE inhibitors
or ARBs at optimal doses reduces the risk of mortality by 15-25% and anticoagulation for
people with heart failure who have atrial fibrillation reduces risk of stroke by 60-70%.
When a variety of different pharmacological options are available, positive benefits are
achievable if the drugs are provided appropriately and patients are supported to be
concordant with their treatment.1,2
The NSF and associated guidelines, underpinned by audit and evaluation, emphasise the
need for improved access to diagnostic services (including echocardiography and B-type
natriuretic peptide (BNP) testing), and robust clinical management involving non
pharmacological and pharmacological treatment, including resynchronisation device
therapy, assist devices and transplantation. Once the diagnosis of CHF is confirmed,
patients can be started (often sequentially) on appropriate medication and a care pathway
with the aim of relieving symptoms, improving health-related quality of life, and reducing
morbidity and mortality.1,9
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The role of Primary Care in delivering improvement (QOF) 2011/12
There is good evidence that appropriate diagnosis, treatment and management can
improve quality of life and help reduce admissions and readmissions, morbidity and
mortality2
The General Medical Services Quality and Outcomes Framework (QOF) manages chronic
diseases in primary care and incorporated three measures on the diagnosis and
management of heart failure. However, there is still wide variation in the number of
patients on GP disease registers with suspected heart failure. Local prevalence of recorded
heart failure mostly falls short of predicted levels1, which could indicate that there is a
largely unseen demand for investigations, clinical assessment and care. The role for Primary
Care service is to implement reliable interventions described in this guide and then to focus
intensively on managing CHF patients safely.
Data Quality System (DQS) in Wales and Audit+
In November 2007, the Welsh Government’s Primary Care Informatics Programme (now
part of NHS Wales Informatics (NWIS) launched the Data Quality System. This was a
natural progression from previous initiatives with the aim of providing an efficient,
automated and consistent software tool, primarily to support General Medical practices and
as a by-product support the bigger picture within Wales.
The DQS comprises of a General Practice based tool, ‘Audit+’ and a secure central NHS
Wales-based web repository ‘Audit Web’ which receives scheduled automated aggregate
data submissions from Audit+.
Participation in the DQS within Wales is voluntary; Audit+ is provided free to all General
Practices in Wales irrespective of their clinical information system and is now deployed in
97% of General Practices. To ensure continued acceptance from practices, reflected in
continued high level of participation, the development and implementation of all modules is
discussed with GPC (Wales) representatives to guarantee ongoing professional approval.
NWIS works closely with Public Health Wales and other key NHS organisations to produce
modules within Audit+ including amongst others:










INR Monitoring
Minor Surgery
Learning Disabilities
Near Patient Testing
QOF age/sex standardised prevalence
Flu vaccinations
Pneumococcal vaccinations
Communicable diseases
CHD National Service Framework
Diabetes National Service Framework / Directed Enhanced Service
As is the case with any software product the results produced are only as good as the
source data supplied. Audit+ therefore contains specific searches within other modules to
encourage General Practices to improve the data quality within their clinical system that
supports their day-to-day activities. Audit+ modules to support cardiovascular risk will
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also contain such searches to ensure that the data required to undertake risk calculations
is as complete as possible.
Registration process
The Audit+ product collects data from all practices who have signed up to its use. The
Practice or service provider will be undertaking testing and measurement of ideas using the
improvement methodology as part of a collaborative, made up of themselves and other
practices or service providers. The precise size and form of the collaborative will be
determined over the coming months.
It will be a voluntary subscription to undertake the interventions described in this
improvement guide. In order to filter data from the Audit + tool, to feed back to practices
who have subscribed to the collaborative(s), the 1000 Lives Plus programme will need to
identify who has subscribed to which collaborative (defined by its improvement focus e.g.
Chronic Heart Failure). In order to do this, the practice, once signed up to a collaborative,
will need to register and accepted that they have agreed to take part in the particular
collaborative(s). The registration will take place using the existing “Public Health Wales
PCQIS Quality Improvement Tools”, which will be familiar to many GP practices because it
hosts the all Wales clinical governance self assessment tool. There will be 1000 Lives Plus
collaborative registration form available at this site. Practice Registration Form
Purpose of the Registration Form
The Registration Form will allow practices and other providers to register their subscription
to one or more of a number of quality improvement collaboratives covering a range of
clinical practice issues, starting with a choice of



Chronic Heart Failure (Left Ventricular Systolic Dysfunction)
Atrial Fibrillation
Anti coagulation therapy using warfarin
Practices or other service providers will be able to sign up to one or more of these
collaborative. The registration tool will allow practices to add data that the Audit + tool is
not collecting but is important to the subject matter. It will also allow practices to annotate
issues or constraints associated with their audit/measurement ranging from internal
practice issues, practice development issues identified or lack of services that may prevent
the implementation of evidence based quality improvements. It will also provide summary
data collection forms for those not signed up to the Audit+ tool.
The issues identified from data collected from the registration form will allow any analysis
to be qualified with constraints and caveats to promote a more effective discussion of
quality improvement within collaborative learning sessions.
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Aim
1000 Lives + Chronic Heart Failure H2G
Interventions
Driver
Care Bundle 1
Refer all patients with previous MI for
echocardiography if not already done post
MI *
 Patients presenting with persistent
breathlessness should be clinically
assessed for the possibility of Heart Failure
 Perform an ECG on all patients with
suspected Heart Failure
 If ECG abnormal refer for echocardiograph
 If ECG normal measure Plasma B-Type
Natriuretic Peptide (BNP). If BNP raised
refer for Echocardiogram
 If AF present use CHADS2 score to assess
need for anticoagulation
Diagnosis &
Investigation
Reduce
Morbidity
for
patients
With
CHF
(LVSD)
Care Bundle 2
 Treat all who can tolerate therapy and
for whom there are no contraindications,
initially with an ACE/ARBs Inhibitor at low
dose, titrating upwards to maximum1
 Use licensed beta-blocker therapy for
patients with Left Ventricular Systolic
Dysfunction (LVSD), where there are no
contra-indications and optimisation of dose
to maximum tolerated (resting heart rate
<65 b.p.m
 Provide aldosterone antagonists to all patients
who are NHYA 2-4 after optomisation of ACEI/ARBs and BB 3
Effective drug
therapy
Effective
clinician/patient
Partnership
Reducing the Risk
of infections
Care Bundle 3
 Patients should be given verbal and
written information about their condition
(See appendix...main guide)
 Patients should have a clear discharge plan
from secondary care and an agreed self
management plan
Care Bundle 4
 Offer Influenza and Pneumococcal
Immunisation
* If unsure, check through hospital letters for mention of a recent echo report prior to
referral for the patients who are symptomatic post MI.
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Getting Started
The practice needs to think about their current local systems and processes and use this
guide as a starting point to think creatively about ideas to test.






Engage the rest of the practice team and ensure effective communication systems
are in place
Assign roles and responsibilities around CHF
Reflect and review, as a team, on what you are doing (integral to PDSA method).
Involve the practice nurse (eg. assessing patients for risk factors, using information
management systems to identify and recall patients, setting up health displays to
encourage patient education so that patients ask about managing their condition)
Involve administration staff (eg. using information management systems to identify
and recall patients)
Identify and action opportunities to clean data (eg. reception staff check patient
information)
Setting Up your team:

Identify a clinical lead (Lead GP)

Identify a managerial lead (GP, Practice Manager, Practice Nurse)

Clarify who is responsible for day to day leadership (Practice Manager)
See Appendix A for further information
Do you and your team understand how to apply the Model for Improvement?
The Model for Improvement is a fundamental building block for change and you need to
understand how to use it to test, implement and spread the interventions in this guide.
See page 16 for further details on the Model for Improvement and the ‘How to Improve’
Guide.
What should we be doing?
PCQIS has used the evidence gathered to produce the driver diagram to summarise
desired outcomes and how they can be achieved.
The driver diagram will help the practice translate a high level improvement goal into a
logical set of underpinning, evidence-based goals (‘drivers’). It captures an entire change
programme in a single diagram and also provides a measurement framework for
monitoring progress.
Care Bundles
The driver diagram details a series of 4 care bundles. Care Bundles are elements of
evidence based research which can be delivered to a selected group of patients. It
provides a systematic approach to care delivery to ensure a uniformity of implementation.
When performed collectively, reliably and continuously, the bundles have been proven to
improve patient outcomes. (See page 9).
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How are you going to measure process reliability?
In order to improve outcomes for your patients you need to demonstrate you are using
these interventions reliably. This means that all the interventions within each bundle
MUST be complied with to achieve successful completion of that bundle. You need to do
this by using the process measures in this guide.
See the ‘How to Improve’ Tools for Improvement guide and Appendix C for a summary of
all process measures.
Drivers and Interventions - Supporting Evidence
This section details the evidence that underpins the driver diagram that has shown to be
effective in treating Chronic Heart Failure.
As a practice (or at least one GP and one other staff member), choose an area where you
feel you need improvement in order that your practice is in line with the evidence. Choose
an area where there is likely to be a significant gap between what you currently do and
what the evidence based guidelines suggest you do or where your level of delivery is
below what you would wish.
Where the recommendations diverge from usual practice explore these recommendations
in more detail. Each recommendation is discussed in detail in the full Heart Failure Nice
guideline: http://www.nice.org.uk/CG108 or NICE Pathways:http://pathways.nice.org.uk/
See helpful resources (appendix E number 1)
Remember The Chronic Heart Failure Bundle is a series of interventions related to heart
failure care that, when implemented together, will achieve significantly better outcomes
than when implemented individually.
Bundle 1- Diagnosis & Investigation
http://guidance.nice.org.uk/CG108/QuickRefGuide/pdf/English
Recommendation
Refer all patients with previous MI for echocardiography if not already done post MI.
Note: First consider those patients who have a past diagnosis of a MI and who present
with symptoms, even if mild15
Rationale
Heart Failure is defined, clinically, as a syndrome in which patients have typical symptoms
(e.g. breathlessness, ankle swelling, and fatigue) and signs (e.g. elevated jugular venous
pressure, pulmonary crackles, and displaced apex beat) resulting from an abnormality of
cardiac structure or function.7
The typical presentation of heart failure in primary care is insidious, with progressive
breathlessness on exertion, ankle swelling, orthopnoea or paroxysmal nocturnal
dyspnoea. Not all patients will have all these symptoms, and in many patients there may
be other causes. 15
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Refer directly to echocardiography if a patient has a history of myocardial infarction or
basal crepitations or is a male with ankle oedema. 15
i) Perform an ECG on all patients with suspected Heart Failure
Recommendation
Patients suspected of heart failure should be identified and an ECG performed and
referred in a systematic way.1
Rationale:
NICE recommend either a natriuretic peptide or an ECG being performed as a triage test
prior to echocardiography. NICE guidance is of the opinion that performing an ECG should
be part of the general assessment of a patient in whom heart disease is suspected to
determine the patient’s rhythm, heart rate control, the presence of conduction
abnormalities, the duration of the QRS complex (to determine the appropriateness of
cardiac re-synchronisation therapy), and to monitor heart failure patients having their
beta-blocking doses up-titrated. While it is no longer recommended as part of the
diagnostic algorithm for heart failure (being replaced by natriuretic peptide), NICE wished
to emphasise that the electrocardiogram remains an essential test to be performed in all
patients with heart failure.
ii) Echocardiography at diagnosis.
Recommendation
Patients at risk of heart failure and those suspected of heart failure should be identified
and assessed and referred for echocardiography in a systematic way1
Rationale:
All patients with acute or chronic heart failure require confirmation of the underlying
structural or functional abnormality. Echocardiography allows assessment of systolic and
diastolic ventricular function including left ventricular ejection fraction (LVEF). It also
assesses chamber size, wall thickness, regional wall motion abnormalities and valvular
function. As part of the referral process for the Specialist Heart Failure Nursing Service an
echocardiogram needs to have been undertaken.
iii) B-type Natriuretic Peptide (BNP) monitoring
Recommendation
If a GP suspects heart failure, then the key blood test is B-type natriuretic peptide (BNP).
If the BNP is normal then heart failure is unlikely and other diagnoses should be
considered. If it is raised, or if there is a past history of myocardial infarction, the patient
requires further assessment, which must include echocardiography and a specialist
assessment. There should be a clear practice pathway or practice protocol in place to
ensure patients are assessed and referred appropriately.1
Rationale:
Performing BNP as a first-line test for heart failure:
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Performing a BNP test or an ECG as an initial test for patients with suspected heart failure
can be recommended as these tests have high sensitivity for detecting heart failure 1, 2.
Heart Failure is unlikely if these test results are considered to be normal. Patients who are
found to have a normal BNP and ECG can proceed on to other disease care pathways so
that their diagnoses can be reached without further unnecessary delay.
Patients with suspected heart failure and no previous MI – measure serum natriuretic
peptides:
 If high levels, refer within 2 weeks for Doppler 2D echocardiography and specialist
assessment.
 If mild to moderately raised levels, refer within 6 weeks.
NICE guidance 2010 recommends the following:
1. BNP>400 pg/ml (>116 pmol/l) or NT-proBNP>2000 pg/ml (>236 pmol/l): Need an
echocardiogram and specialist clinical assessment no longer than 2 weeks from the time
of presentation
2. BNP 100-400 pg/ml (29-116 pmol/l) or NT-proBNP 400-2000 pg/ml (47-236 pmol/l):
Need an echocardiogram and clinical assessment by the Specialist within 6 weeks from
the time of presentation.
3. BNP <100 pg/ml (<29 pmol/l) or NT-proBNP <400 pg/ml (<47 pmol/l), in the absence
of heart failure therapy: Heart Failure is an unlikely cause for the presentation.
IV) Atrial fibrillation
Recommendation
Patients with persistent/permanent Atrial Fibrillation (AF) should be started on anticoagulants
Rationale:
Patients with AF are at risk of forming small thrombi within the heart chambers that can
embolise and cause stroke or TIA. CHADS2-VASc scores will assess likely risk in order to
determine the need for anticoagulation.10
The CHADS2 VASC scoring system has superceded the old CHADS2 scoring system and is
the preferred tool for stroke/ TIA risk assessment in patients with AF See helpful
resources (appendix E number 2).
Bundle 2 - Effective drug therapy
http://guidance.nice.org.uk/CG108/QuickRefGuide/pdf/English
i)
Recommendation
Patients with heart failure due to left ventricular systolic dysfunction must be routinely
considered for ACE-inhibitor treatment and beta blockers,.
Rationale:
The morbidity and mortality rates of heart failure have progressively fallen through the
accumulative effects of several classes of agents including angiotensin converting enzyme
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inhibitors, beta-blockers, aldosterone antagonists, combined arterial and venous dilators
(combined hydralazine and nitrates) and angiotensin receptor blockers. These advances
have been achieved in the treatment of heart failure associated with reduced left
ventricular ejection fraction or HF with LVSD, which comprises almost 50% of the heart
failure patient population. Systematic reviews of randomised control trials have established
that ACE inhibitors improve symptoms, reduce the risk of hospitalisation for heart failure
and increase life expectancy, compared with placebo. The beneficial effect is more evident
in those patients with severe symptoms. In patients truly intolerant of ACE-inhibitors, ARBs
can be used as an alternative but it is likely they are not as effective in reducing hard endpoints.
Beta-blockers can significantly improve mortality and reduce hospitalisation in patients with
all grades of heart failure. Beta-blocker therapy is recommended in all patients with CHF in
addition to standard therapies of ACE inhibitors and diuretics, regardless of whether
symptoms persist or not. Several systematic reviews provide consistent evidence of the
benefits of beta-blockers compared with placebo.
NICE1 and SIGN 11guidelines therefore recommend that licensed beta-blockers should be
used when initiating therapy in heart failure. Only Bisoprolol, Carvedilol and Nebivolol (in
patients aged over 70 years) currently have heart failure as a licensed indication in the UK.
Current NICE guidance1 states that patients who are already taking beta-blocker therapy
(e.g. atenolol) when they develop heart failure can either continue with their current betablocker or change to a licensed alternative. Switching to a licensed beta-blocker may be an
improved option, as evidence suggests the benefits of beta-blockers may not be a class
effect.
Very often it is the dose of beta-blocker that is not tolerated rather than the drug per se. It
is better to give a low dose of beta-blocker than none at all, while individualisation of
dosage is critical to allow all eligible patients, including older people, to benefit from the
treatment. However, more cardioselective beta-blockers, in particular nebivolol (and
possibly bisoprolol) are often tolerated when others have not been and should be
considered in this circumstance.
It is important to start at a low dose, up-titrate the beta-blocker doses gradually to the
target or highest tolerated dose and defer therapy in patients who are not stabilised and/or
have more than minimal evidence of fluid overload or volume depletion. Therapy should be
provided to all eligible patients, provided that the patient is stable, does not meet exclusion
criteria and will receive follow-up.
ii)
Recommendation
In addition to an ACE inhibitor and a beta-blocker consider adding an aldosterone
antagonist licensed for heart failure (especially if the patient still has symptomatic
heart failure [NYHA class II–IV] or has had a MI within the past month) 1
Rationale:
The aldosterone antagonist spironolactone can be added to an ACE inhibitor and a betablocker in patients who continue to remain symptomatic; low doses of spironolactone
reduce symptoms and mortality in these patients. If spironolactone cannot be used,
eplerenone may be considered for the management of heart failure especially after an
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acute myocardial infarction with evidence of left ventricular systolic dysfunction. Close
monitoring of serum creatinine, eGFR, and potassium is necessary, particularly following
any change in treatment or any change in the patient’s clinical condition. 12
Bundle 3 - Effective clinician/patient Partnership
Recommendation
There should be clear communication between clinicians and patients as to further
management. Ideally every patient should have a written self management plan and be
considered for referral to a specialist heart failure (nurse-led) team.
Rationale:
Patients who understand their condition better and what the treatment is for cope better.
Patients are frustrated when they feel there is lack of communication between secondary
and primary care. Poor planning is more likely to lead to readmission. Encourage patients to
recognise deterioration of their symptom control, give them confidence in obtaining advice
and assistance from Specialist CHF Nurses. (See appendix E helpful resources).
Discharge planning to take account of the following: patient and carer wishes and the level
of care and support that can be provided in the community – this information should be
accessible to the primary care team; specific behavioural/lifestyle issues that can affect the
risk of development and progression of CHF; information of who to contact for advice and
support immediately following discharge and patient information leaflets or booklets.
Bundle 4 – Reducing the Risk of infections
Recommendation
All patients without contraindication should be offered immunisation for Influenza and
Pneumococcal infection.
Rationale:
Influenza and pneumococcal immunisation are included as components of the care bundle
based on recommendations from the Advisory Committee on Immunisation Practices
(ACIP). ACIP recommends special priority for immunisation of individuals with pulmonary
or cardiac disease13and influenza immunisation reduces the risk of hospitalisation for
patients with heart failure.
Pneumococcal vaccine is especially recommended for persons with heart failure. It is
most effective in preventing invasive disease, for which heart failure patients are at higher
risk. Vaccination is a primary care intervention, as responsibility for providing
immunisation falls under the General Medical Services Contract. Practitioners from any
care environment should inform and encourage CHF patients to ensure they receive this
protection.
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How do we introduce changes to processes?
Making improvements to products, systems or services requires change. Although change
can seem threatening or overwhelming for busy people, it can be successfully managed if
well planned.
The Model for Improvement
The Model for Improvement provides a framework for developing, testing and implementing
changes. It helps to break down the change effort into small, manageable chunks which are
then tested to ensure that things are improving and that no effort is wasted. It is always
worth remembering that while every improvement is certainly a change; every change is
not an improvement.
The Model for Improvement consists of two equal parts; the first part, the ‘thinking part’,
consists of three fundamental questions to guide improvement work:
• What are we trying to accomplish?
• How will we know that a change is an improvement?
• What changes can we make that will result in an improvement?
The second part, the ‘doing part’, is made up of rapid, small ‘plan, do, study, act’ (PDSA)
cycles to test and implement change in real work settings. The PDSA cycle provides a
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framework for testing ideas and assessing the results to determine if the change is an
improvement and shares many attributes with the classic audit approach.
PDSA is a model for testing ideas that you think may create improvement in a situation. It
can be used to test ideas for improvement quickly and easily based on existing
knowledge, research, feedback, theory, review, audit, or by adapting practical ideas that
have been proven to work elsewhere.
The answer (or answers) to the third fundamental question: ‘What changes can we make
that will result in an improvement?’ will form the ‘change ideas’ (or objectives) to lead
each PDSA cycle. It is important to remember that a project will usually be broken down
into a number of PDSA cycles.
There are many things to consider and techniques to employ, which are captured in the
‘Appendix B– The Model for Improvement Driver Diagram.
See Appendix C for further guidance on PDSA cycles to assist you to make changes in
your practice that can be used to support the implementation of the Heart Failure Driver
Diagram.
Successful improvement initiatives don’t just happen – they need careful
planning and execution
In any improvement initiative you need to succeed in three areas. You need to generate
the Will to pursue the changes, despite difficulties and competing demands on time and
resources. You need the good Ideas that will transform your service. Finally you need to
Execute those ideas effectively to get the change required.
Will
The interventions you need to build Will are explained in the ‘Leading the Way to Safety
and Quality Improvement’ and ‘How to Improve’ guides. They concentrate on raising the
commitment levels for change and then providing the project structure to underpin
improvement approaches. Spreading changes to achieve transformative change across
the whole health system requires strong leadership.
We need to create an environment where there is an unstoppable will for improvement
and a commitment to challenge and support teams to remove any obstacles to progress.
Ideas
The interventions in this guide describe ideas which evidence shows to be effective for
achieving changes that result in improvements. It gives examples from organisations that
have achieved them and also advice based on their experience. Methods and techniques
for generating new ideas or innovative ways to implement the evidence can be found in
the ‘How to Improve’ guide and other improvement literature.
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Execution
However, to bring these ideas into routine practice in your organisation, it is essential that
you test the interventions and ensure that you have achieved a reliable change in your
processes before attempting to spread the change more widely.
How will we know that a change is an improvement?
In order to answer this, practices will need a defined process measure (such as
compliance with all elements of a care bundle) which is evidently linked to an outcome
measure (such as an increase in the numbers of referrals for echocardiograph). Both
process and outcome data which are linked are essential to evaluate the effectiveness of
change.
The data the practice collects in real time can be used to tell the improvement story and
build the case and/or argument to change practice in order to improve outcomes.3
To improve outcomes for patients the practice needs to demonstrate that they are using
the interventions in the driver diagram reliably. This means that all the elements of the
interventions are performed correctly on 95% or more of the occasions when they are
appropriate (A lower limit may be acceptable in small population sizes or where there are
variable that are beyond control).
Note
There should be a measure of compliance with each main indicator.
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How do we measure for Improvement?
Start collecting the data and using it for local decision making using the Seven Steps to
Measurement:
In this Chronic Heart Failure Guide, steps 1-3 have been established:
Step 1 - What are we trying to accomplish?
An aim needs to be Specific, Measurable, Achievable, Realistic and
Time-bound (SMART). Everyone involved in the change needs to understand what this is
and be able to communicate it to others: To reduce morbidity for patients with CHF
(LVSD)
Step 2 - How will we know that change is an improvement?
It is essential to identify what data is needed to answer this question and how to interpret
what the data is telling us.
Step 3 – Define measures
The process measures have been defined and are listed in appendix C (Page 28).
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Practices now need to implement steps 4-7-(CAR) collect, analyse, and review
data.
The key is to go round the Collect-Analyse-Review cycle frequently:
 Collect your data
 Analyse - turn it into something useful like a run chart
 Review - meet to decide what your data is telling you and then take action.
Successful improvement projects all have clear aims, robust measurement and
well-tested ideas. Use the ‘How to Improve’ guide to ensure your projects have all
three.
Step 4 – Collect your data
The practice will need to know their baseline before they can track the progress of their
goal against it.
Continuous data collection will be collected mainly via the Audit+ software within your
practice. Data will be analysed and fed back to practices and local networks by the
Primary Care Quality Information Service (PCQIS).
The first collection of your data will provide a ‘baseline’ of current performance. Thereafter
running and reviewing the data collection at an agreed frequency will give you a more
regular idea of how well you are doing.
Practices may wish to allocate their own standards to the recommended process
measures following a review of their baseline data from PCQIS
By starting measurement and plotting points the practice will be able to create their
baseline. To create a baseline or identify a trend the practice can start using a run chart.
A run chart is a simple line graph which is used to track the performance of one (or more)
steps in the process targeted for improvement across a defined period of time.
“Practices may be able to develop their own run charts from Audit + data at the practice
which will be available more frequently than the PCQIS reporting”


Run charts are the visual expression of the process measure developed. Plotting the dots’
is very effective because it will help the practice spot trends and patterns displayed about
25 data points are ideal. However, 20 data points will provide a robust representation.
One way to get more points is to measure more frequently. Often the data needed to
measure is not being collected. If so, the practice should start collecting data straight
away. But the practice does not have to wait to start making small changes. They will not
affect the overall situation so you can be doing those while creating the practice baseline.
Run charts can:
Help improvement teams formulate aims by depicting how well, or poorly, a process is
performing.
Help in determining when changes are truly improvements by displaying a pattern of data
that the practice can observe as they make changes.
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Give direction as work on improvement and information about the value of particular
changes.
Further information on the construction, interpretation displaying time series data and analyses
of run charts can be found at How to Improve’ Guide.
http://www.1000livesplus.wales.nhs.uk/home
Why collect data?
 How can the practice compare, quantify or record changes if the practice have not
captured any data.
 Without measurable data the practice is at the mercy of anecdote. If the practice
make an assumption based on anecdote rather than data, it will nearly always be
wrong because people remember the unusual, not the mundane.
 How will the practice know that any changes they have made will result in an
improvement?
Note: Continuous data collection will be collected mainly via the Audit+ software. Data will
be analysed and fed back to practices and local networks.
Step 5 - Analyse
Improvement takes place over time. Therefore, determining if improvement has really
happened and if it is lasting requires observing patterns over time.
Step 6 – Review your data to decide what it is telling you
It is vital that the practice set time aside to look at what the measures are telling them.
The frequency with which the practice collect, analyse and review their data sets the pace
for change for improvement.
How will the practice know that a change is an improvement?
1. By understanding the variation that lives within the data.
2. By making good decisions on improvement choices (i.e. don’t overreact to a special
cause and don’t think that random movement of your data up and down is a signal of
improvement).
One of the key strategies in improvement is to control variation- Further reading on Variation, as
a measure of quality can be accessed at
How to Improve’Guide http://www.1000livesplus.wales.nhs.uk/home
Step 7 – Repeat steps 4 to 6
This is an iterative process. The purpose of measurement is to lead the practice to making
the right decisions about their improvement project. Even if the practice are consistently
meeting their goals they should still look to see if there are further improvements that
could be made. If the practice aimed for 0% or 100% and are meeting it reliably the
practice should still continue to measure so that any deviations are picked up and acted
upon quickly.
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In these cases the practice may decide to measure less frequently, however be aware that
the process of measuring does have a positive effect in keeping awareness high and
demonstrating that the goals measured is important to the practice.
Remember:

Plot data over time - Tracking a few key measures over time is the single most
powerful tool a team can use.

Seek usefulness, not perfection. Remember, measurement is not the goal;
improvement is the goal. In order to move forward to the next step, a team needs
just enough data to know whether changes are leading to improvement.

Use sampling. Sampling is a simple, efficient way to help a team understand how
a system is performing.

Integrate measurement into the daily routine. Useful data are often easy to
obtain without relying on information systems.

Use qualitative and quantitative data. In addition to collecting quantitative
data, be sure to collect qualitative data, which often are easier to access and highly
informative.

Understand the variation that lives within your data. Don’t overreact to a
special cause and don’t think that random movement of your data up and down is a
signal of improvement
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How to successfully introduce change and Build the will to make improvements
After testing a change on a small scale, learning from each test, and refining the change
through several PDSA cycles, the change is ready for implementation on a broader scalefor example, for an entire practice population or on an entire unit.




Achieving change will require consistently applying a range of improvement initiatives
into the daily work of the practice.
Strong leadership within the practice is critical to building the will to change
Setting clear improvement aims and monitoring progress against them is a primary
task for the practice
Commitment to develop practice staff at all levels in the skills needed to lead and
deliver improvement initiatives.
Implementation is a permanent change to the way work is done and, as such, involves
building the change into the practice. It may affect documentation, written policies,
hiring, training, and aspects of the practice infrastructure that are not heavily engaged in
the testing phase.
Spreading Changes
Spread is the process of taking a successful implementation process from a pilot unit or
pilot population and replicating that change or package of changes in other parts of
practice organization.
During implementation, teams learn valuable lessons necessary for successful spread,
including key infrastructure issues, optimal sequencing of tasks, and working with people
to help them adopt and adapt a change.
Locality based Learning sessions
Pockets of excellence exist in our Primary Care health care systems, but knowledge of
these better ideas and practices often remains isolated and unknown to others.
A schedule of local learning events (Primary Care collaborative) will be delivered within
each Health Board locality to share data/learning issues emanating from practices. This
communication method will provide an opportunity for adopters to ask questions, explore
solutions among colleagues, share learning, and deepen their understanding of the
changes the practices are making.
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References
1. National Clinical Guidelines Centre (2010) Chronic Heart Failure CG108: The management of chronic heart
failure in adults in primary and secondary care (revised).
http://www.nice.org.uk/CG108
2. National Heart Failure Audit 2012
http://www.ucl.ac.uk/nicor/audits/heartfailure/additionalfiles/pdfs/annualreports/annual12.pdf
3. European Society of Cardiology guidelines for the diagnosis and treatment of acute and chronic heart failure
2012
http://www.escardio.org/guidelines-surveys/esc-guidelines/GuidelinesDocuments/GuidelinesAcute%20and%20Chronic-HF-FT.pdf
4. The Cardiac Disease National Service Framework for Wales
June 2009: Standard 4 managing the care of patients with chronic heart failure
http://www.wales.nhs.uk/sites3/Documents/338/090706cardiacNSFen%5B1%5D.pdf
5. Chronic Heart Failure toolkit PCQIS
http://www2.nphs.wales.nhs.uk:8080/primarycareqitdocs.nsf/Main%20Frameset?OpenFrameSet&Frame=Rig
ht&Src=%2Fprimarycareqitdocs.nsf%2Fcategorypublicpage%3FOpenPage%26ExpandView%26RestrictToCate
gory%3DToolkit%26AutoFramed
6. Welsh Medicines Resource Centre; Treatment of chronic heart failure (November 2008)
http://www.wemerec.org/Documents/Bulletins/ChronicHeartBulletOnline.pdf
7. European Society of Cardiology (ESC) 2008 Acute and chronic Heart Failure Clinical Practice Guidelines
http://www.escardio.org/guidelines-surveys/esc guidelines/GuidelinesDocuments/guidelines-HF-FT.pdf
8. CKS chronic heart failure 2010 http://www.cks.nhs.uk/heart_failure_chronic
9. Healthcare Commission (2007) pushing the boundaries: improving services for people with heart failure.
London: Commission for Healthcare Audit and Inspection.
http://www.wales.nhs.uk/documents/Pushing_the_boundaries_Improving_services_for_patients_with_heart_f
ailure_200707042319.pdf
10. The Cardiac Disease National Service Framework for Wales
June 2009: Standard 4 managing the care of patients with chronic heart failure
http://www.wales.nhs.uk/sites3/Documents/338/090706cardiacNSFen%5B1%5D.pdf
11. NICE TA 197 Atrial Fibrillation – dronedarone: guidance
http://www.nice.org.uk/nicemedia/live/13115/50469/50469.pdf
12. Scottish Intercollegiate Guidelines Network (2007) Management of Chronic Heart Disease
http://www.sign.ac.uk/pdf/sign95.pdf
13. British National Formulary No 62 Sept 2011
http://bnf.org/bnf/bnf/current/
14. Centre for Disease Control (2006) Morbidity & Mortality Weekly Report, July 28, CDC: Atlanta
http://www.cdc.gov/mmwr/pdf/rr/rr5510.pdf
15. Development and initial validation of a simple clinical decision tool to predict the presence of heart failure
in primary care Eur J Heart Fail. 2012 Sep;14(9):1000-8. Epub 2012 Jun 19.
http://www.ncbi.nlm.nih.gov/pubmed/22713289
http://www.ncbi.nlm.nih.gov/pubmed/22916582
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Appendix A - Setting up your team
Achieving improvements that reduce harm, waste and variation at a whole organisation
level needs a team approach: one person working alone, or groups of individuals working
in an uncoordinated way will not achieve it and this applies equally at all organisational
levels.
Whether your improvement priorities relate to 1000 Lives Plus content areas, national
intelligent targets or other local priorities, you need to consider three different dimensions
in putting your team together:

Identify a clinical lead (Lead GP, Practice Nurse)

Identify a managerial lead (GP, Practice Manager, Practice Nurse)

Clarify who is responsible for day to day leadership (Practice Manager)
There may be one or more individuals on the team working in each dimension, and one
individual may fill more than one role, but each component should be represented in order
to achieve sustainable improvement.
Clinical lead (GP, Practice Nurse)
A senior clinician should always be given delegated accountability for a specific content
area in this case Chronic Heart Failure; and all practice staff working on the changes
should know who this is. This individual needs sufficient influence and authority to allocate
the time and resources necessary for the work to be undertaken at the practice. It is
essential that this individual has full authority over the areas involved in achieving the
improvement aims. It is essential that practice staff have an understanding of the
improvement methodology and to base conversations around the interpretation of
improvement data. Reporting of progress to higher organisational levels should also use a
consistent data format so that the Executive level leader can report to the Board on
progress.
Managerial lead (GP, Practice Manager or Practice Nurse)
A clinical or technical expert is someone who has a full professional understanding of the
processes in the content area. It is critical to have at least one such champion on the
team who is intimately familiar with the roles, functions, and operations of the chronic
heart failure content area. This person should be interested in driving change in the
practice. (Identify individuals who are not afraid to try changes).
Patients can provide expert advice to the improvement team within the practice, based on
their experience of the system and the needs and wishes of patients. A patient with an
interest in the improvement of the system can be a useful member of the team.
Additional technical expertise may be provided by an expert on improvement
methodology, who can help the team to determine what to measure, assist in the design
of simple, effective measurement tools, and provide guidance on the design of tests.
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Day to day leadership (GP, Practice Manager or Practice Nurse)
Frontline leaders will be the critical driving component of the practice team, assuring that
changes are tested and overseeing data collection. It is important that this person
understands not only the details of the system, but also the various effects of making
changes in the system. They should have skills in improvement methods. This individual
must also work effectively with the technical expert. They will be seen as a bridge
between the organisation leadership and the day-to-day work and ensuring accurate and
timely data collection for process and outcome measures related to the content area
(Chronic Heart Failure).
Characteristics of a good team member
In selecting team members, you should always consider those who want to work on the
project rather than trying to convince those that do not. Some useful questions to
consider are the following:
 Is the person respected for their judgment by a range of staff?
 Do they enjoy a reputation as a team player?
 What is the person’s area of skill or technical proficiency?

Are they an excellent listener?

Is this person a good verbal communicator within and in front of groups?
 Is this person a problem-solver?

Is this person disappointed with the current system and processes and
passionately want to improve things?
 Is this person creative, innovative, and enthusiastic?
 Are they excited about change and new technology?
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Appendix B – Model for Improvement Driver Diagram
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Appendix C - PDSA Cycle - How to test change
PDSA cycles are a process to assist you to make changes in your practice that can be
used to support the implementation of the Heart Failure Driver Diagram.
It is recommended to start small – one person, one setting, and one service provider.
Even if something has been shown to work in other settings, take the time to do a smallscale trial. There are almost no ‘plug and play’ solutions that work in all situations. Testing
allows us to adapt actions to particular settings. To test a new procedure or technique,
the practice need to ‘plan, do, study and act’ as explained below.
Plan
Plan what you are going to do differently i.e., as a practice (or at least one GP and one
other staff member), Choose an area where there is likely to be a significant gap
between what you currently do and what evidence based guidelines suggest you do.
Where the recommendations are consistent with your practice spend little or no time
reading these, but where they diverge from usual practice explore these
recommendations in more detail.
Do
Carry out the plan and collect information on what worked well and what issues need
tackling.
The first data collection will provide a ‘baseline’ of current performance (the starting
part). The practice should plot the results on a chart, this will provide an ideal number
of points to create a baseline or identify a trend. One way to get more points is to
measure more frequently. The practice may find the information needed is not
currently being collected. If so, start collecting the relevant information straight away.
Displaying Observed Data in a time Sequence
A run chart is a simple line graph which is used to track the performance of one (or more)
steps in the process targeted for improvement across a defined period of time. Run charts
are the visual expression of the process measure developed. Plotting the dots’ is very
effective because it will help the practice spot trends and patterns displayed.
For more on Run charts go to: http://www.1000livesplus.wales.nhs.uk/methodology ‘How
to Improve’ document mentioned in the last paragraph has a section on run charts.
Study
Gather relevant team members as soon as possible after the test for a short informal
meeting. Analyse the information gathered and review the aim of the new procedure or
technique against what actually happened. Questions that need to be asked include:
 ‘What is the information telling us?’
 What worked and what didn’t work?’
 ‘What should be adopted, adapted, or abandoned?’
Act
Use this new knowledge to plan the next test. Agree the changes and amend the
outcome measures if necessary.
Continue testing in this way, refining the new procedure or technique, until it is ready to
be fully introduced. But, do it quickly (think in days, not weeks).
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Appendix C
Process Measures
To assess the application of the driver diagram interventions, the following search criteria (as per audit + software) will be collected
and analysed by PCQIS and reported back to individual practices.
Audit+
Driver: Diagnosis and Investigation
process measure
Care Bundle One
Refer all patients with previous MI for
echocardiography if not already done
post MI
Perform an ECG on all patients with
suspected Heart Failure
Descriptor
Total
1A
denominator
All patients who have an MI (ever) have had an
echocardiogram recorded after the diagnosis
1B
denominator
1C
If ECG abnormal refer for
echocardiograph
All patients with new diagnosis of HF due to LVSD (i.e. pick
up HF and LVF/LVSD code) within the last 12 months
(including MI patients)
All patients with new diagnosis of HF due to LVSD within the
last 12 months and have ECG recorded within 2 months
before or 2 months after the LVSD code (including MI
patients)
All patients with new LVSD diagnosis within the last 12
months and who have had a normal ECG (including MI
patients) who have then had a BNP test
1E
If ECG normal measure Plasma B-Type
Natriuretic Peptide (BNP) If BNP raised
refer for Echocardiogram
All patients with a record of MI ever
1I
All patients with new LVSD diagnosis within the last 12
months with an abnormal ECG who have had BNP test
(including MI patients)
IJ
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Audit+
Driver: Effective Drug Therapy process measure
Treat all who can tolerate therapy and for whom there
are no contraindications, initially with an ACE/ARBs
Inhibitor at low dose, titrating upwards to maximum
Care Bundle Two
Descriptor
Total
Use licensed beta-blocker therapy for patients with Left
Ventricular Systolic Dysfunction (LVSD), where there are
no contra-indications and optimisation of dose to
maximum tolerated (resting heart rate <65 b.p.m.
2A
denominator
All patients coded with Heart Failure and LVSD
over 3 months since diagnosis
2B
All patients with HF and LVSD over 3 months
who are being prescribed ACEI minus CI to ACEI
2G
All patients with HF and LVSD over 3 months
who are being prescribed beta-blocker therapy
minus those who have a CI to beta-blockers
denominator
2K
All patients with HF and LVSD over 3 months
who remain NYHA II-IV whilst taking ACEI/ARB2
and Beta Blockers
2L
All patients with HF and LVSD over 3 months
who remain NYHA II-IV (whilst taking ACEI/ARB2
and Beta-Blockers) and who are being prescribed
an aldosterone antagonist
Provide aldosterone antagonist to all pts who are NYHA
2-4 after optimisation of ACE1/ARBs and BB
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Care Bundle
Three
Driver: Effective clinician/ patient partnership process
measure
Descriptor
Total
Patients are provided with verbal and written
information about their condition. Patients are provided
with a clear discharge plan from secondary care and an 3A
agreed self management plan
Driver: Reducing the risk of infection process measure
Care Bundle Four
Audit+
All patients with a diagnosis of HF due LVSD (over
3 months since diagnosis) who have a self
management plan
Audit+
Patients with LVSD have an immunisation for
pneumococcal pneumonia documented
4A
Patients with LVSD who have an immunisation for
influenza documented
Descriptor
Total
4C
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All patients with a diagnosis of HF due LVSD (over
3 months since diagnosis) who have
pneumococcal recorded (ever)
All patients with a diagnosis of HF due LVSD (over
3 months since diagnosis) who have had influenza
vac in the last 18 months
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Appendix D
1000 Lives + Chronic Heart Failure H2G
Relevant suggested read codes for process measures
Care bundle one
Diagnosis & Investigation
Patients who have an MI
recorded
Relevant suggested READ Codes
G30..
G32..
G30..%
acute myocardial infarction
old myocardial infarction
Acute myocardial infarction (excluding G30A.)
G35..% Subsequent myocardial infarction
G38..% Postoperative myocardial infarction
Gyu34[X]Acute transmural myocardial infarction of unspecified site
Gyu36[X]Subsequent myocardial infarction of unspecified site
Patients who have had a MI
should have an
Echocardiogram after the
event
Patients with a new diagnosis
of Heart Failure due to Left
Ventricular Systolic
Dysfunction (LVSD)
8HQ7.
56F1.
Referral for echocardiography
Echocardiogram declined
G58..% Heart failure
G581.% Left ventricular failure.
G5yy9 Left ventricular systolic dysfunction
21264 Heart failure resolved
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Patients with LVSD who have
had an ECG
Patients with LVSD who have
had an echocardiograph to
confirm diagnosis
Patients who have had a
normal ECG
1000 Lives + Chronic Heart Failure H2G
321B. 12 lead ECG
32... Electrocardiography
3211. ECG requested
3215. ECG not done
5853.11 U-S heart scan
585R.
Echocardiogram normal
5C20.
Echocardiogram equivocal
585g.
Echocardiogram shows left
ventricular diastolic dysfunction
585f.
Echocardiogram shows ventricular systolic dysfunction
3216. ECG normal
R1431 [D]Electrocardiogram (ECG) abnormal
32140 Ambulatory ECG normal
321..% ECG-general
3215. ECG not done
Care bundle 2
Relevant suggested READ Codes
Effective Drug Therapy
Patients coded with Heart
Failure due to Left Ventricular
systolic dysfunction (LVSD)
Patients with LVSD prescribed
ACE-inhibitor without
contraindications for ACEinhibitor recorded
G58..% Heart failure
G581.% Left ventricular failure.
G5yy9 Left ventricular systolic dysfunction
8I28 Angiotensin converting enzyme inhibitors contraindicated
U60C4
[X]Angiotensin-converting-enzyme inhibitors causing adverse effects in
therapeutic use
8I3P.
Angiotensin II receptor antagonist
14LM H/O Angiotensin converting enzyme inhibitor allergy
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ZV14D[V] Personal history of ACE inhibitor allergy
8I3D Angiotensin converting enzyme inhibitor declined
8B6H. ACE target dose achieved
8B6Q. Patient on maximal tolerated ACE inhibitor therapy
TJC77 Adverse reaction to captopril
TJC78 Adverse reaction to enalapril
TJC79 Adverse reaction to ramipril
8I74 Angiotensin converting enzyme inhibitors not tolerated
bk3.. to bk5z. Losartan, Valsartan, Irbesartan
bk7.. to bk9z. Candesartan, Telmisartan, Eprosartan
bkB..% Olmesartan
bkD..% Amlodipine and Valsartan
bkC..% Hydrochlorothiazide and Olmsartan
8I64. Angiotensin converting enzyme inhibitor not indicated
bA..% Calcium channel blockers and ACEI
bk6..% Trandolopril and verapamil hydrochloride
14LN.00 H/O Angiotensin II receptor antagonist therapy (ARB) allergy
U60CB00 [X] Angiotensin II receptor antagonist (ARB) causes adverse effects in
therapeutic use.
Patients with LVSD prescribed
beta-blocker therapy without
contraindications for betablocker recorded
bd...
TJC6.
U60B7
242..
bdf..%
bdl..%
bdm..%
14LL.
BETA-ADRENOCEPTOR BLOCKERS
Adverse reaction to beta-blockers
[X]Beta-adrenoreceptor antagonists causing adverse effects
in therapeutic use, not elsewhere classified
O/E - pulse rate
Bisoprolol fumarate
Carvedilol
Nebivolol
H/O beta-blocker allergy
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Patients with LVSD prescribed
ACE1 or ARB2 and betablocker therapy and remain
symptomatic (i.e. NYHA II-IV
after optimisation)
Patients who remain
symptomatic (ie NYHA II-IV
after optimisation) of
prescribed aldosterone
antagonist
1000 Lives + Chronic Heart Failure H2G
U60B9
Adverse reaction to bisoprolol
U60BA
Adverse reaction to carvedilol
U60BB
Adverse reaction to nebivolol
ZV14C
Personal history of beta-blocker allergy
ZVu6i
Personal history of allergy to bisoprolol
ZVu6o
Personal history of allergy to carvedilol
ZVu6q
Personal history of allergy to nebivolol
8I26.
Beta-blocker contraindicated
8I73.
Beta-blocker not tolerated
8I2g. to 8I2i. Bisoprolol, Carvedilol, Nebivolol contraindicated
8I7K. to 8I7M. Bisoprolol, Carvedilol, Nebivolol not tolerated
8IAS. to 8IAV. Bisoprolol, Carvedilol, Nebivolol therapy refused
8I36.
Beta-blocker therapy refused
b43..
SPIRONOLACTONE
b45..%
EPLERENONE
662f
NYHA stage I
662g
NYHA stage II
662h
NYHA stage III
662i
NYHA stage IV
8I2L.
Spironolactone contraindicated
TJE44
Adverse reaction to spironolactone
U60E1[X] Mineralocorticoid antagonists [aldosterone antagonists] causing
adverse effects in therapeutic use
8I3K0
Spironolactone declined
8I3K.
diuretic declined
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Care Bundle 3
Effective clinician/ patient
partnership process
measure
Patients are provided with
verbal and written
information about their
condition Patients are
provided with a clear
discharge plan from
secondary care and an
agreed self management
plan
Relevant suggested READ Codes
8CMK.
8CL3.
Has heart failure management plan
Heart failure care plan discussed with patient
Care bundle 4
Relevant suggested READ Codes
Diagnosis & Investigation
Patients with LVSD have an
immunisation for
pneumococcal pneumonia
documented
n4b.. PNEUMOCOCCAL VACCINE
65720 Pneumococcal vaccination given
657P. Pneumococcal vaccine given by another provider
U60J8. Pneumococcal vaccination causing adverse effect in therapeutic use
ZV14G Personal history of pneumococcal vaccination allergy & 14LR. H/O:
pneumococcal vaccine allergy
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Patients with LVSD have an
immunisation for influenza in
the last 18 months
documented 4C
1000 Lives + Chronic Heart Failure H2G
65E... Influenza vaccination
n47..% Influenza vaccine
ZV048 Influenza vaccination
14LJ. H/O influenza vaccination allergy
U60K4 [X]Influenza vaccine causing adverse effects in therapeutic use
ZV14F [V]Personal history of influenza vaccine allergy
68NE. No consent - influenza imm.
9OX5. Influenza vaccination declined
14LJ. H/O: influenza vaccine allergy
8I6D. Influenza vaccination not indicated
8I2F. Influenza vaccination contraindicated
U60K4 [X]Influenza vaccine causing adverse effects in therapeutic use
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Appendix E-Helpful Resources
The Traffic Light self-management tool, adapted from an Institute of
Healthcare Improvement resource.
Well evaluated by patients and carers, as a tool for recognising deterioration of their
symptom control, and giving them confidence in obtaining advice and assistance from
Specialist CHF Nurses.
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Chronic Heart Failure Management Guidelines October 2012
Heart Failure suspected – If no previous MI and normal ECG, exclude heart failure by measuring NTproBNP. Raised
levels need echocardiogram based specialist assessment – within 2 weeks if severely elevated (>2,000ng/l).
HF with
preserved
ejection fraction
Give diuretics to relieve
congestion and fluid retention.
Use loop diuretics at low to
moderate dose together with ‘traffic
light’ daily weighing.
Add MRA – spironolactone 25-50mg
daily for persisting oedema or
dyspnoea (with renal function
monitoring or specialist advice).
Provide exercise-based
rehabilitation and patient
information
Aim for tight control of risk
factors e.g. HTN, DM, AF, obesity,
raised cholesterol
Manage chronic conditions in line
with NICE guidance:
Use an ACEI for:

HTN above 135/80

MI: secondary prevention

Chronic kidney disease

Atrial fibrillation rate
control to resting rate
< 80 b.p.m. with heart
failure beta-blocker
Use a statin following vascular risk
assessment or inherited
hyperlipidaemia
Provide exercise-based rehabilitation
and patient information to all. Offer to
discuss prognosis and symptoms.
http://www.heartfailurematters.org
Heart Failure due to Left Ventricular
Systolic Dysfunction
Loop diuretic to relieve fluid retention
+
ACE-inhibitor, only check BP if postural
symptoms. Check U&E after 1-week and
increase dose
or
ARB if truly intolerant to ACE-inhibitor
Intolerant to ACE-inhibitor and ARB even
when starting low and going slow?
Add hydralazine plus nitrate after
introduction of BB and MRA
Cardio-selective Beta Blocker
“Start low and go slow”
Avoid bradycardia <50 b.p.m.
Add MRA (spironolactone 25-50mg daily)
for persisting oedema or dyspnoea NYHA
2-4 (with renal function monitoring or
specialist advice for CKD 4 and 5).
Do not initiate or increase dose if patient
overloaded with fluid (with exception of fast
AF)
U&E monitoring week 1,2 & 4 then monthly
for 3 months and three monthly thereafter
for higher risk patients
If resting heart rate >70b.p.m and sinus rhythm despite full beta blockade, add ivabradine
5mg, increasing to 7.5mg bd (2.5mg in elderly)
QRS complex >150ms or
QRS 120-149 ms plus echo dysynchrony
echo EF< 35%
→ Refer for CRT +/- Defibrillator
Persisting symptoms? Discuss end of life
issues in detail
Consider adding:

Digoxin low dose only if effective
for relief of symptoms
OR

Hydrazaline in combination with a
nitrate especially in people of
African or Caribbean origin with
moderate to severe heart failure.
Definition of Terms:
HF
heart failure
HTN
hypertension
MI
myocardial infarction
MRA mineralocorticoid receptor antagonist
BB
beta blocker
ACEI angiotensin converting enzyme inhibitor
ARB
angiotensin receptor blocker
Author
LVSD Primary
left ventricular
systolic dysfunction
Care Quality and Information Service
eGFR estimated glomerular filtration rate
EF
ejection fraction Version; 1
CRT
cardiac resynchronisation therapy
LVAD left ventricular assist device
Date
December 2012
39
Persisting NYHA III/IV
Consider:

LVAD, transplantation

End of life care
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North Wales Cardiac Network
Atrial Fibrillation / Atrial Flutter Management Pathway (AF)

All chronic disease clinics or clinical
New onset Atrial
Fibrillation/Atrial Flutter with
symptoms LVAD,
Further investigations:
Acute Medical admission
recommended
 Pharmacological cardioversion
 Electrical cardioversion
 Ablation for flutter
Permanent
Accepted and
longstanding
Attempt rate control only
picion
TFT, Persisting symptoms?
Stroke Risk Stratification/thromboprophylaxis for all patients
http://www.nice.org.uk/guidance/index.jsp?action=byID&o=116
C over)
46) or CHA2DS2VASc score (see
+
AF
ACE-inhibitor
 History
and examination
Long standing
or persistent
Paroxysmal
Not
self terminating,
lasting > 7 days up
Recurrent episodes lasting
 Manual
pulse check
monthspulse,
(or more
with previous
usually <48 hours, max 7 days
toIf 12
irregular
perform
an ECGorto confirm
successful cardioversion)
 Consider Heart Failure diagnosis requiring echo (not BNP) if ECG
ARB
intolerant
to ACE-inhibitor
has abnormal QRS
or ifTtruly
waves
but slowly
control heart rate first.
Rhythm control
Consider rhythm control if <65 years or
Identify
trigger factors
symptomatic with AF, secondary
to
a
treated
e.g. candesartan, valsartan, in
(e.g. alcohol)
corrected precipitant.
Otherwise use rate control
“Start low and go slow”
Management advice:
Start standard ß blocker (bisoporolol or carvedilol)
or rate limiting calcium antagonist (Verapamil or
Diltiazem) if no LVSD
 Titrate to achieve resting ventricular rate of <80 b.p.m.
or <110b.p.m. on exercise
 Add digoxin for resting rate control if resting ventricular
rate persists >80 b.p.m.

Management advice:
Start standard ß blocker (bisoprolol or carvedilol) or
rate limiting calcium antagonist (Verapamil or Diltiazem) if ß
blocker not tolerated and no LVSD
ure
Planned Electrical Cardioversion – use warfarin 3-4 weeks
beforehand and at least 3 weeks after.
OR

Digoxin low dose only if effective for relief of
symptoms
Refer for specialist opinion if patient still symptomatic.
Likely to be offered:
OR on referral. Amiodarone (permanent AF) or
 Electrical cardioversion / EPS ablation so need warfarin initiation
Dronedarone (non permanent AF) can be used (short term <6/12) to increase success of ECV.
 Pharmacological “pill in the pocket” therapy may be useful for
 paroxysmal
Hydrazalineevents.
in combination with a nitrate
especially in peAn aldosterone antagonist
licensed for treatment of heart failure e.g.
spironolactone,
especially
moderate
The aim in all patients is to fully relieve all symptoms
and for the
stroke in
risk
to be to
low.
severe heart failure or MI in the past month OR
Key:
Green = Primary Care
Red = Secondary Care
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ople of African or Caribbean origin with
audience:
moderateIntended
to severe heart
failure. Public (internet)/NHS
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
40
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North Wales Cardiac Network 2011
Atrial Fibrillation / Atrial Flutter Management Pathway (AF)
Who needs Warfarin? Usually those with at least 1 other risk factor for stroke. Annual risk of stroke
is 1% per annum in the young and fit (5% over 5 years), increasing with age and other risk factors
for all types of atrial fibrillation and flutter.The following links assist in the assessment of risk/benefit
of warfarin treatment: http://nntonline.net
Risk factors for stroke in non-valvular AF
Major risk factors
Previous stroke
TIA or systemic
embolism
Age ≥ 75 years
Risk factor-based point-based scoring
system – CHA2DS2-VASc
Clinically relevant nonmajor
risk factors
CHF or moderate to severe
LV systolic dysfunction
(e.g. LV EF ≤ 40%)
Hypertension
Diabetes mellitus
Age 65-74 years
Female sex
Vascular disease
Adjusted stroke rate according to CHA2DS2-VASc
CHA2DS2-VASc
score
0
1
2
3
4
5
6
7
8
9
Patients
(n =
7329)
1
422
1230
1730
1718
1159
679
294
82
14
Adjusted stroke
rate (%/y)
0%
1.3%
2.2%
3.2%
4.0%
6.7%
9.8%
9.6%
6.7%
15.2%
Risk Factor
Congestive heart failure/LV
dysfunction
Hypertension
Age ≥ 75 years
Diabetes mellitus
Stroke/TIA/thromboembolism
Vascular disease
Age 65-74 years
Sex category (i.e. female
sex)
Maximum score
Score
1
1
2
1
2
1
1
1
9
Clinical characteristics comprising the HASBLED bleeding risk score; if >3, need strict
control of INR
Letter Clinical characteristic
Points
awarded
H
Hypertension
1
A
Abnormal renal and liver
1 or 2
function ( 1 point each)
S
Stroke
1
B
Bleeding
1
L
Labile INRs
1
E
Elderly (e.g. age > 65
1
years)
D
Drugs or alcohol (1 point
1 or 2
each)
Maximum
9 points
Patients with mitral stenosis, prosthetic heart valves or risk score >1 usually require
warfarin. Where antithrombotic therapy is given:

The most effective treatment (reduces stroke risk by 2/3), is adjusted-dose
Warfarin (target INR 2.5, range 2.0 to 3.0). USE WHOLE mg DOSES.
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


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Where Warfarin is not indicated, give aspirin 75 to 300 mg/day +/- clopidogrel
75mg daily (both reduce stroke risk additively by 1/5 each). Consider
gastroprotection.
If Warfarin is appropriate, do not co administer aspirin purely for
thromboprophylaxis, as it provides no additional benefit. Aspirin may be
continued if clearly indicated separately.
Clopidogrel has a similar benefit to Aspirin but increases the bleeding risk when
used concurrently.
Initiation of Warfarin:
 There is no need to achieve anticoagulation rapidly; a slow loading regimen
is safe and achieves therapeutic coagulation in the majority of people within 34 weeks.
 Ensure appropriate monitoring of INR using clinical support software. See BNF
for potential drug interactions.
Atrial Flutter: Rate and rhythm control can be more difficult
 DC cardioversion and / or ablation are more successful so earlier referral is
indicated.
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Appendix F – Glossary
Acronym / Term
Description
ACEI
Angiotensin-converting enzyme inhibitors (treatment for high blood
pressure and heart failure).
AF
Atrial fibrillation (irregularly irregular rhythm of the heart).
ARB
Angiotensin receptor blocker (treatment for high blood pressure and
heart failure)
BB
Beta blocker (treatment for heart rhythm, angina and heart attacks,
high blood pressure and heart failure)
BNP
B-type natriuretic peptide (a protein substance secreted from the heart
wall especially when stretched or when the pressure within it has risen)
BP
Blood pressure
.
CHD
Coronary heart disease.
CHF
Chronic heart failure.
ECG
Electrocardiogram (Recording of the electrical activity of the heart)
ECHO
Echocardiography (is a diagnostic test which uses ultrasound waves to
make images of the heart chambers, valves and surrounding
structures. It can measure cardiac output and is a sensitive test for
inflammation around the heart (pericarditis). It can also be used to
detect abnormal anatomy or infections of the heart valves.
HF
Heart failure.
LVADs
Left ventricular assist devices (Sophisticated device, implanted
surgically to help a badly failing heart, to pump blood into the circulation)
LVEF
Left ventricular ejection fraction (the percentage of the volume of the
blood that leaves the heart with each beat, this is a measure of the
pumping function of the left pumping chamber of the heart)
LVSD
Left ventricular systolic dysfunction (The condition where the left
pumping chambers ability to pump is impaired. This is characterised by
low left ventricular ejection fraction, and leads to heart failure)
MI
Myocardial infarction (Heart attack)
NICE
National Institute for Health and Clinical Excellence
NP
Natriuretic peptide (A protein substance secreted by the wall of the heart
when it is stretched or under increased pressure. It has several forms)
NSF
National Service Framework. Policies set out by the National Health
Service to clearly define standards of care for major medical issues
NTproBNP
N-terminal pro-B-type natriuretic peptide (One of the natriuretic
peptides, protein substances secreted by the wall of the heart when it is
stretched or under increased pressure. It has several forms)
NYHA
New York Heart Association (functional classification): (These allow an
assessment of the patients ability to carry out exercise before they
develop their symptoms
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