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GEORGE ELIOT HOSPITAL NHS TRUST Heart Failure Nursing Service and Rehabilitation. Operational Guide. Author Emma West-Eggar Heart Failure Clinical Nurse Specialist. Version 1.0 21st December 2015. This pathway has been developed as a guide to help Practitioners understand the Heart Failure Nurse referral process for both the George Eliot Hospital Trust and NHS Warwickshire North CCG General Practitioners. Contents Contents Aims of the Service Heart Failure Nurse Referral Criteria Heart Failure Nurse Hospital Inpatient Pathway Heart Failure Nurse Outpatient Pathway Heart Failure Rehabilitation Phases Discharge criteria Appendix Page 1 2 3 4 5 6 9 10 1 Aims Of The Heart Failure Nursing Service This operational guide is designed to provide Health Professionals with an overview of the Heart Failure Nursing Service at George Eliot Hospital NHS Trust. The Heart Failure Nursing Service aims at optimising care for patients with a diagnosis of Left Ventricular Systolic Dysfunction with an Ejection Fraction of <45%. Education and self-management of patients diagnosis and symptom control is essential using a variety of different written/verbal and visual aids and is the primary aim of the service. Other services include Heart Failure medication titration, an individually tailored education and exercise programme using the Cardiac Rehabilitation model. The Heart Failure Nurse Service is based at George Eliot Hospital and care is primarily provided by a Heart Failure Clinical Nurse Specialist and a Consultant Cardiologist with a Specialist interest in Heart Failure. The Heart Failure Nursing Service operates Monday to Friday 8-4pm and can be accessed by patients, relatives and any Healthcare Professional. The Heart Failure Clinical Nurse Specialist has the opportunity to work closely with the Consultant Cardiologists and will liaise with them if treatment plans are uncertain or complex. The Heart Failure Team comprises of three Consultant Cardiologists and One Heart Failure Clinical Nurse Specialist. Dr Asok Venkataraman – Consultant Cardiologist Dr Suresh Krishnamoorthy – Consultant Cardiologist Dr Babak Nazari – Consultant Emergency Medicine Emma West-Eggar – Heart Failure Clinical Nurse Specialist Heart Failure Nurse Office contact – 024 76 153841. The Heart Failure Team Provide: 1) 2) 3) 4) 5) Ward based consultations Telephone support Heart Failure Clinics including Heart Failure medicine titration Education and training for patients, carers and other professional groups Comprehensive exercise programme based at George Eliot Hospital depending on suitability 6) Community exercise classes depending on suitability. 2 Inclusion and exclusion inpatient/Outpatient criteria for the Heart Failure Nursing Service George Eliot Hospital NHS Trust. Referral criteria for the Inpatient & Outpatient Heart Failure Nursing Service. Inclusion Criteria. 1) Patients with LVSD <45% on echocardiogram either on current admission or previous reports with any of the following: a) Inoperable valve disease. b) Patients diagnosed with Atrial Flutter/Fibrillation NOT suitable for any further cardiac procedures. c) Inoperable coronary artery disease. d) Patients diagnosed with a Myocardial Infarction (MI) and NOT suitable for revascularisation. e) Any other Cardiac aetiology deemed appropriate for referral via Consultant Cardiologist only. Exclusion Criteria. 1) Confirmed Diastolic impairment without LVSD on echocardiogram. 2) Less than 6 weeks post Myocardial Infarction with LVSD. (6 week post MI echocardiogram needed prior to HF referral). If LVSD <45% on 6 week echocardiogram, refer to the Heart Failure Team. 3) Patients awaiting clinical intervention for Atrial Flutter/Fibrillation i.e. Cardioversion. 4) Operable valve disease. 5) Uncontrolled cardiac arrhythmia with a borderline/near normal EF or systolic function. 6) Life limiting co-morbidity with a terminal prognosis (refer to Palliative Care Team). 3 George Eliot Hospital Inpatient Heart Failure Nurse Pathway. Patient referred prior to discharge. Ward refer patient to HFN according to HFN inclusion/exclusion criteria. Please see HFN referral guidance. HFN reviews patient, HF medication introduced or titration and education. Cardiac Rehabilitation offered depending on suitability criteria. (Phase 1) HFN requests cardiologist to review/plan prior to discharge. Patient discharged home. HFN makes post discharge phone call to check progress (phase 2) Invite to education programme (phase 3). yes HF plan implemented prior to or during admission Did the patient see Cardiologist as an inpatient? No Patient requires a new HF consultant follow up appointment. Patient attends outpatient appointment for follow up with HFN. Review patients at HF MDT Review in HFN clinic until patient is suitable for Cardiac Rehabilitation Programme or dicharged from service. yes Are there any concerns about the patient? No Patient to attend Cardiac Rehabilitation exercise programme depending on suitability (phase 3). Discharge patient to Cardiologist/GP/Palliative Care/Community Matrons. Discharge to phase 4 community exercise programme if suitable. 4 George Eliot Hospital Outpatient Heart Failure Referral Pathway Patient referred via GP with suspected signs and symptoms of Heart Failure. New or Existing diagnosis of Heart Failure? NTpro BNP >400 or LVSD <45% Existing Heart Failure patients with confirmed diagnosis of Heart Failure by Cardiologist and LVSD <45%. Please refer via Heart Failure Nurse referral form. New patients suspected of having Heart Failure. Please refer using Diagnostic Heart Failure Clinic referral form. Does the patient need to be seen within 2 weeks? No Yes Seen by Consultant Cardiologist in Heart Failure Clinic. Patient to be referred to Hot Clinic, Ambulatory Care Unit at GEH. Confirmed LVSD Ejection Fraction <45% Yes Management plan by Cardiologist as per NICE and ESC guidelines. Cardiologist referral to HFN. No Cardiology clinic if appropriate. Seen by HFN in clinic Clinical assessment, medication titration, education and promotion of self-management. Invite to exercise programme if suitable. When agreed treatment plan completed, plan to discharge patient as per NICE guidelines 2010. Discharge to Palliative Care Team, GP, Community Matrons or continue to monitor in Cardiology Clinic as an outpatient. HFN Discharge to phase 4 Community exercise programme if suitable. 5 Heart Failure Rehabilitation Phases. Phase 1 Phase 1 Inpatient Heart Failure (HF) Rehabilitation includes: Inpatient review of HF symptoms, HF medication, HF aetiology and its precipitating factors. Teaching and education of HF and its physiological processes to both patients and carers. Empowering patients to self-manage symptoms of HF using the Heart Failure Top Tips guidance. ( see appendix 1) Offering a patient medication diary to all patients to encourage patient participation in collating important information such as daily weights and blood pressure readings. Offering individually tailored verbal/written risk factor modification information such as smoking, alcohol and blood pressure information in line with current evidence based research. Offer a follow up telephone call by the HF Nurse to assess symptoms on discharge from hospital (phase 2) and to assess patient compliance with medication. Offer exercise rehabilitation classes if patient meets the British Association for Cardiovascular Prevention and Rehabilitation (BACPR) criteria. Provide contact details so that patients have access to Specialist HF advice Monday-Friday 8-4pm. Organise a date for follow up HF clinic with either Cardiologist or HF Nurse. 6 Phase 2 Phase 2 Outpatient Heart Failure Rehabilitation includes: Follow up phone call on discharge to include: 1) Clinical assessment of HF symptoms and to address any concerns the patient or carer may have. 2) HF medication compliance. 3) Reiterate top tips for Heart Failure and reinforce the importance of patient compliance. 4) To assess suitability for exercise rehabilitation. 5) To confirm Outpatient follow up with either Cardiologist or HF Nurse. 6) Assess identified risk factor modification and patient compliance. Patient to attend Outpatient HF follow up clinic. All new patients not seen as an Inpatient and meet the HF inclusion criteria will be followed up by the HF Nurse as a new patient. All phase 1 information will be discussed during this appointment. Medication titration and clinical examination will also be included in the appointment. Phase 3 Phase 3 Exercise and Education Rehabilitation includes: Education Package 1) 2) 3) 4) 5) All patients will be offered an education package based at George Eliot Hospital and will include: What is Heart Failure and the physiological process? Heart Failure medications and the importance of patient compliance. Exercise and Heart Failure. Self-management of Heart Failure symptoms and risk factors. Stress and relaxation. 7 Exercise Package. Patients deemed suitable for the HF exercise programme will receive the following package: 1) Pre-exercise assessment with a Cardiac Physiotherapist to assess suitability and fitness level for class participation. 2) Patients will be offered up to a maximum of 16 exercise sessions depending on patients symptom control and wellness. The exercise programme will be individually tailored to the patient and prescribed on a session by session basis depending on progression. N.B patients may be unable complete the full course to due to non-attendance or relapse in condition. Patients may be invited to complete the full course if possible. 3) Heart Failure symptoms and risk factor management will be reviewed prior to discharge from the exercise sessions. Patients will be discharged from the hospital service and offered the opportunity to participate in the phase 4 community exercise classes if suitable. Phase 4. Phase 4 Heart Failure Rehabilitation will include: The opportunity for eligible patients to participate in a community exercise package with “Fitter Futures”. Patients to continue to be cared for by their own General Practitioner in the community or any other Health Care Professional involved with the patients care. 8 Discharge Criteria Patients can qualify for one or a combination of the following: Patients who are fully titrated on their HF medication or have reached optimal treatment. Exercise Rehabilitation has been completed and treatment plan has been completed. They have been referred to the Palliative Care Team, Community Matrons, Virtual Ward or any other Specialist Teams to take over care of the patient. Patient request. Failure to attend Outpatient appointments. Patients who are fully titrated or have reached optimal treatment and have been discharged to the Community Phase 4 programme. Please note: Referral back to the service should be via the GP or the Inpatient team, not by the patient to the relevant Cardiologist. 9 Apendix 1 Heart Failure Top Tips 1) Weigh yourself daily every morning after your first visit to the toilet. Please ensure you are wearing minimal clothing before weighing yourself. Ensure that the scales are placed on a flat hard surface and not carpet. Record each weight in your Heart Failure Diary. It is important that you inform your GP, or Heart Failure Nurse Specialist if your weight increases by 3-4 pounds (2kg) within 3-4 days. 2) Drink 7-8 mugs of fluid a day, approximately 3 and a half pints or 2 litres. 3) Seek advice from your GP or Heart Failure Nurse Specialist if you notice any of the following symptoms: Waking at night with shortness of breath or coughing Weight increase of 3-4 pounds in 3-4 days You feel short of breath doing things that do not normally make you feel breathless. New or increased ankle swelling or stomach bloating. 4) Ensure you have your annual Flu vaccination and a once only anti-pneumonia vaccine. 5) Do not add salt to your diet and avoid foods that have a high salt content. Do not use low Salt or Salt substitutes. 6) Please ensure that you take your Heart Failure Diary to ALL appointments and ensure all information is kept up-to-date. 7) Please keep your diary up-to-date, including adding any new medication prescribed. 8) Eat a healthy well balanced diet. Please seek advice from your Heart Failure Nurse Specialist for more information. 9) Please ask your GP surgery for a Heart Failure booklet if you do not have one. 10) Never stop taking your medication unless you are told to do so by your Nurse or Doctor. Do not run out of your tablets. 10 GEORGE ELIOT HEART FAILURE NURSE REFERRAL FORM Date Sent:……………………….….. Date Received:…………..…….………….. Appointment:……………….…………… PATIENT DETAILS GP DETAILS Name.................................................................... Male/Female DOB…………………………………….. NHS Number: ………………………………………………. Address:……………………………………………… ………………………………………………………… ……………………………………………………………… ………….. Post Code:………………………………………………… Tel No: (essential)……………………………………………. Hospital/NHS Number:……………………………………………… GP Name……………………………………………………… ……. Practice Names: ………………………………………………… Practice Address stamp Tel:….................................................................... Fax:………………………………………………………… …………. Investigation results to be provided with Referral ECG (MUST be included with referral) ECHO must be performed with LVSD & EF <45% U&Es, Creatinine, FBC, Glucose, Liver Function tests, Thyroid function tests, Lipids. Please Note: this from is for patients with a confirmed diagnosis of Heart Failure via Cardiologist with an Ejection Fraction of <45%. Patients with NEW signs and symptoms of Heart Failure should be referred via the Diagnostic Heart Failure Clinic referral form. 1. 2. 3. 4. 5. 6. 7. Symptom Review Breathlessness Orthoponea Reduced Exercise Tolerance Peripheral Oedema PND Fatigue/Lethargy Other please specify Yes/No Yes/No Yes/No 1. 2. 3. Past Medical History Previous MI Yes/No History of Angina Yes/No Hypertension Yes/No Yes/No Yes/No Yes/No Yes/No 4. 5. 6. 7. Valvular Disease Heart Murmur Arrhythmias Other please specify Yes/No Yes/No Yes/No Yes/No Reason For Referral. Current Medication (please attach printout if available) Please Fax this referral to the number given below: Telephone for enquiries: 024 76 153841 Fax Number for referral: 024 76 865704 Office use only: Appropriate referral – Yes/No If inappropriate, state destination of final referral 11 12