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