A guide for review and improvement of hospital based heart failure services

NHS
CANCER NHS Improvement
Heart

DIAGNOSTICS

HEART

NHS Improvement
LUNG
A guide for review and
improvement of hospital based
STROKE
heart failure services

Contents

Section 1 3

Introduction 3

The impact of heart failure 3

Recommended components of a heart failure service 4

Section 2 5

Service review 5

Section 3 7

Heart failure management issues in secondary care 7

Appendix 1 13

Appendix 2 13

Authors

Dr David Walker, Consultant Cardiologist, Hastings and Rother NHS Trust
and NHS Improvement National Clinical Lead

Elaine Kemp, National Improvement Lead, NHS Improvement

Acknowledgements

Dr James Beattie, NHS Improvement National Clinical Lead

Dr Mark Dancy, NHS Improvement National Clinical Chair

Ms Janine O’Rourke, NHS Improvement National Clinical Advisor

Mr Michael Connelly, NHS Improvement National Clinical Lead

Dr Nigel Rowell, NHS Improvement National Clinical Lead

A guide for review and improvement of hospital based heart failure services 3

Section 1

Introduction
Figure 1: LOS/readmission rates

The information in this document
has been brought together by NHS
Improvement, to help hospital
teams to review their heart failure
(HF) service.

Nationally, there is marked variation
in the length of stay and
readmission rate for heart failure in-
patients (fig 1). It might be argued
that a longer than average length of
spell reflects close attention to
detail, to ensure that care is
optimised prior to discharge.
However, if this is the case it should
be reflected in a low readmission
rate, which often it is not.
Alternatively a short length of stay The national heart failure audit1
might indicate a very efficient
The impact of heart
also highlights that:
service – or conversely one where failure
pressure on beds leads to • Within a year of admission for
inappropriate early discharge before Heart failure affects one in a heart failure, 32% of patients
management is complete. The hundred people in the UK, around died
“Holy Grail” of short length of spell 620,000 people, increasing to • Mortality is significantly better for
and low readmission rate does exist around 7 percent over the age of those who have access to
but is currently rare in the UK. 75. In 2009/10 Hospital Episode specialist care i.e. those seen by
Statistics (HES) data showed there cardiologists or specialist heart
For providers where both of these were 73,752 hospital spells for heart failure services (23 per cent).
indicators are above the national failure (coded in the first position)
average, a systematic review of with a mean length of stay of 11.76
services may help to identify days and a median of 8 days. Ten
problem areas and direct percent of patients (8,385) were In 2009/10, Basildon and
subsequent improvement work. The readmitted with heart failure in Thurrock University Hospital
two main aims of completing a under 29 days. The government reduced their heart failure
review are to optimise the time a proposal not to pay hospitals for this admissions median length of
patient spends in hospital, with type of readmission in the future stay from 12 days to four
early diagnosis and treatment, and means providers will be under days, releasing 1,249 bed days
to maximise the effective use of pressure to reduce unnecessary per year, a cost saving of
resources within the trust and wider readmissions. As an example a £312,250.
NHS community. hospital where 20 patients are
readmitted with an average 5 days This was achieved by
stay could cost £30,000. speeding up the diagnosis,
optimising care quickly and
linking in to community
services for early discharge.

1
National Heart Failure Audit, 2010

www.improvement.nhs.uk/heart

4 A guide for review and improvement of hospital based heart failure services

Recommended 1. System for early accurate diagnosis of outpatients
components of a heart
a.Serum NP testing to streamline referrals from primary care
failure service b.Rapid Access HF Clinic (in primary or secondary care)
c. Echo on the day of clinical assessment
NHS Improvement has reviewed d.Management plan produced on the day
many successful heart failure e.Ensure confirmed HF patients go on heart failure registers
services (HF) services over the last
few years, and this has revealed
considerable consistency in their 2. Optimisation of treatment
organisation. Certain key
a.System for uptitrating medication – hospital or community based
‘components’ are usually present
b.Agreed care plan
and these are outlined in the tables
c. Patient education to facilitate self management
on the right. These components are
d.Access to cardiac rehabilitation
by no means confined to secondary
e.Access to implantable cardiac devices
care settings, and indeed in many
cases are successfully delivered in
primary care. Even though this 3. Identification of heart failure in patients
resource is designed mainly for
secondary care, it is essential to look a.Serum NP and early inpatient echo
at the totality of the service b.Management in dedicated area with expertise – Junior docs/nurses
including the interaction between c. Close liaison/collaborative working with community over discharge
community and hospital. planning
Optimisation of the primary- d.Discharge with a care management plan
secondary care interface around
referral and discharge is critical for
4. Multidisciplinary team working
the efficient use of resources.
a.Case management discussions across primary-secondary care
interface - early discharge, admission avoidance - seamless service
b.Consultant lead/+GP/hospital HF nurse(s)/community HF nurse(s) etc
c. Designated care co-ordination

5. Supportive and palliative care

a.Unnecessary admission avoidance at end of life - preferred priorities
of care
b.Palliative care involvement
c. End of life models for example - Liverpool Care Pathway or the Gold
Standards Framework - community
d.24/7 generic end of life care provision in the community into which
heart failure specialists contribute



Section 2

Service review 2. Characterise the current Using the heart failure audit as
service provision an accurate measure of a
A service review provides key Document and characterise the successful heart failure service is
stakeholders (such as health current service by each hospital site. only appropriate if it is
professionals, service managers and This should include the current representative of all heart failure
patients) with a baseline assessment length of stay and readmission rate patients.
to determine how well a service is in comparison with the national
currently provided and how benchmark. This local HES data can An audit of patient notes confirms
effectively it interfaces with patients. be provided by the trust information where in the patient pathway
This information can then be used department (Appendix 2). constraints repeatedly impinge upon
to prioritise and plan changes for patient care or effective use of
improvement and measure the Hospital Episode Statistics (HES) resources and can be used to check
impact after implementation. data are generated by the hospital the accuracy of HES coding.
coding team, using information
from patients’ notes. Commissioners 3. Share the baseline with key
1. Engage key stakeholders use HES data to calculate the stakeholders
Key stakeholders include anyone payments a service receives. Sharing baseline details with key
who is responsible for, delivers part Apparently inaccurate hospital data stakeholders will help validate the
of, is a user of, or is affected by the requires further investigation data and inform the team. Note -
heart failure service. As a minimum supported by the originating clinical avoid making comparisons between
this team should initially include team, rather than outright rejection. providers or clinical teams as there
representation from the admitting If HES data is incorrect, payment for may be errors in the data or
and receiving medical teams, the services will be incorrect. clinically appropriate reasons for
lead clinician, nurse specialists, the differing indicators.
service manager and patients. This The National Heart Failure Audit
composition of the team may need provides information on heart 4. Map out the process
to be adjusted during the review to failure treatment across the UK, The basic improvement cycle can be
consider specific aspects of the including patient profiles, length of described as ‘PDSA’ – plan, do,
service. hospital admission, interventions, study, act. For more details and for a
medication and outcome. Data wide range of improvement tools
It is important that as well as entry into the national heart failure and techniques click here»
accurate audit data, the opinions of audit is a Care Quality Commission
each of these groups are captured quality indicator. However, currently Involve all stakeholders in creating
and form part of the baseline. not all trusts are entering every and authenticating the process map.
Patient centred care should form the heart failure patient. Patients on
backbone of any change and there whom data has not been collected Map out and record the steps which
are many ways to ensure that are more likely to be those admitted occur in a standard patient pathway,
patients and carers views drive under specialities other than making sure to measure how long
improvement. For further advice and cardiology. It is also likely, and each takes and where there are
guidance click here» supported by the audit itself, that handoffs (management of care or
these are the patients with longer paperwork changes hands). This will
lengths of stay and poorer highlight time where there is no
outcomes. added benefit to patient care.



It is suggested to start the map from Ensure that these proposals are
the time of presentation to the agreed with all the clinical team and
trust, noting where the referral by patient representatives. Support
comes from, through to the time of from the management team is also
first follow-up post discharge. The essential to make sure the changes
stages can be divided, for example, are in line with trust policy.
into presentation and diagnosis,
treatment and optimisation, It is important to set goals for your
discharge and follow-up. improvements. There is very little
point in making changes if you
Review the impact of services which cannot accurately assess whether
feed into and receive patients to the impact made is positive. Set a
and from the in-patient service, such baseline for each of your
as the system for referral from improvements, then regularly
primary care and how patients are measure this goal after the
discharged to community services. improvement is implemented to
ensure it is effective, finally embed
List and quantify the impact of any this measurement into the regular
constraints identified in the process. running of the service so as the
For example, if waiting for an in- ensure that the improvement is
patient echo causes delay, record maintained. An example might be
the waiting time and the number of to reduce the wait for an inpatient
patients waiting. Calculate how echo from the baseline median of
many bed days are wasted each six days, down to two days.
year and what this costs, then
compare this with the cost of 6. Action and reassess
providing additional echo resources, Implementation is a key step. For
to help inform subsequent further advice and guidance look on
decisions. the NHS improvement heart failure
website here»
5. Prioritise and plan
improvements Examples of how other heart failure
Create a list of where improvements service providers have implemented
are required and the order in which change within their service can be
these should be implemented. accessed here»
Section 3 describes some of the
common challenges and suggests
how these might be tackled.

Once you have confidently
identified and measured the
constraints on the service, agree
with the key stakeholders what
actions should be taken to optimise
care and which should be
implemented first.



Section 3

Heart failure management issues in secondary care

Outpatients: Early accurate diagnosis and treatment

1. System for early accurate diagnosis of outpatients

a.Serum NP testing to streamline referrals from primary care
b.Rapid Access HF Clinic (in primary or secondary care)
c. Echo on the day of clinical assessment
d.Management plan produced on the day
e.Ensure confirmed HF patients go on heart failure registers

2. Optimisation of treatment

a.System for uptitrating medication – hospital or community based
b.Agreed care plan
c. Patient education to facilitate self management
d.Access to cardiac rehabilitation
e.Access to implantable cardiac devices

Close integration of HF services Inpatients
across primary and secondary care is Reorganisation of heart failure care
essential at all stages of the patient for inpatients raises a number of
pathway. New patients presenting issues. In an ideal situation, all HF
to hospital with advanced HF or patients should be managed when
known patients presenting with in hospital, by a team led by a
poorly controlled symptoms may be consultant cardiologist or HF
an indication that some patients are specialist, on a specialist ward
not being identified early enough (cardiology or HF).
and treated effectively. The protocol
for initial investigation and However, at present, in many
subsequent referral of suspected hospitals in the UK, HF patients are
new HF patients to specialist spread throughout the medical and
services must be easily accessible to care of the elderly wards. The
all in primary care. Once the reasons for this are many, but
diagnosis has been confirmed, there include elderly age, the presence of
must be an agreed care plan which co-morbidities and the variability of
covers support, up-titration of presentation (and subsequent
medication, subsequent follow up difficulty in rapid identification).
etc. to make sure that patients do Occasionally the influence of co-
not fall through the net. Rapid, morbidities is so significant that
comprehensive intervention in this management based on a care of the
way can often avoid the need for elderly ward is more appropriate.
admission in this high risk group.



Identifying patients admitted with heart failure

3. Identification of heart failure in patients

a.Serum NP and early inpatient echo
b.Management in dedicated area with expertise – Junior docs/nurses
c. Close liaison/collaborative working with community over discharge
planning
d.Discharge with a care management plan

The crucial first step in the
reorganisation of inpatient services In April 2009, West Herts Hospital introduced an integrated HF
is to identify patients presenting pathway in which patients received urgent serum NP testing on
with heart failure. There are two admission, followed by rapid access to echo. Daily cardiology
main options here: ward rounds were then organised to advise on these patients
and optimise treatment and this lead to a significant reduction in
(i) Identification at the front readmissions.
door Serum NP testing also helped identify patients admitted under
This is the ideal situation. Patients another specialty, reducing the time nurse specialists spent
with breathlessness or oedema locating patients and reducing unnecessary echo’s.
suggestive of HF should have an
immediate serum NP measurement.
Patients with a positive or borderline Readmissions
result should then receive
echocardiography in <24 hours to
confirm the diagnosis and suggest
an underlying cause. Once patients
have been identified they can be
directed to the appropriate cardiac
or HF ward, where this is not
currently available aiming to cluster
HF patients onto the same ward
should be a priority. Where there are
multiple problems or major co-
morbidities the patient can receive
shared care on a medical or care of
Cost of bed days saved = £69,000. Cost of providing serum NP = £38,800.
the elderly ward. Overall saving of £30,200 in one year.

Rapid identification and assessment
at the front end of the hospital may
also make it possible to avoid
admission for some patients, with (ii) Identification of patients picture, in-patient echocardiography
the Acute Heart Failure Nurse on the wards is usually requested. Referral for
(AHFN) adjusting treatment and The reality of the current situation is echocardiography without serum NP
arranging early follow up with the that in many hospitals HF patients screening can often overwhelm in-
community HF nurse (CHFN). are scattered throughout the wards. patient capacity and delays in
Access to serum NP for in-patients diagnosis ensue. This inevitably
remains infrequent, and so where delays definitive treatment plans
HF is suspected from the clinical and prolongs hospital stay.



Although inevitably this system is
Note: Redesign of the inpatient more fragmented and time Note: Acute management is
echocardiography service to consuming than option (i), once best delivered on a cardiac or
prioritise these patients can identified by the AHFN, patients can heart failure ward where the
have a significant benefit on receive appropriate input to their nursing and junior medical staff,
length of stay. Definitive management and discharge can be are familiar with the protocols
facilitated via discussions with the
treatment is often not instituted and can respond to
CHFN.
before echocardiographic complications. This is likely to
confirmation of diagnosis and Questions you might consider: underpin the improvement in
this is expensive for the NHS • Are there a high percentage of mortality seen in the HF Audit
and potentially serious for the patients presenting with NYHA for patients managed on cardiac
patients. For further information class 4? (NYHA explained - wards.
www.abouthf.org/questions
on how to calculate demand
_stages.htm).
and capacity click here» • Are the patients presenting to
A&E new presentations, or known Acute management
HF patients decompensating? The more severely unwell patients
• Should the patient be presenting usually require complex treatment
In this situation, the role of the
earlier/elsewhere? regimes which include intra venous
AHFN specialist is critical. They need
• Once admitted, is the process (IV) diuretics - either by intermittent
to make sure that all patients are
geared towards rapid diagnosis? injection or by continuous infusion.
known to the HF team and receive
• Is serum NP used as a predictor to Daily assessments of these patients,
input from the HF consultant. Often
enable patients to enter the is essential to ensure appropriate
this requires "trawling" of the
correct pathway at the door? fluid loss without excessive
wards which is time consuming,
• Is echocardiography available impairment of renal function, or
although providing a "hotline" for
within 24hours of admission/ electrolyte imbalance. In the current
wards to inform the AHFN of
positive serum NP? system in the NHS where junior
suspected patients can reduce the
workload. Additionally some form medical staff, frequently change
Specialist assessment firms, experienced nursing staff
of alert system via the hospital IT
Once identified, all patients should have a major role to play in
system which is activated when
be assessed by the HF specialist monitoring the patients during this
known HF patients are admitted is
team (consultant/nurse) as early as stage. The HF specialist should be
also useful.
possible in their admission, to make available for advice on a daily basis.
appropriate management plans. When the patient is not on a cardiac
Subsequent input from the HF team ward, the AHFN is ideally placed to
can then be stratified according to liaise between the HF specialist and
clinical status i.e. severity of the ward staff.
presentation (new patients) or
deterioration (previously diagnosed
patients).



Appointment of an AHFN and concentration of HF patients on
two wards has reduced in patient mortality in Hastings.

Concentrating HF patients on two wards - General Cardiology and Care
of the Elderly Cardiology, with patients being identified by an acute HFN
‘trawling’ medical assessment ward (without availability of serum NP),
has resulted in a reduction in hospital mortality.

Mortality in hospital 1998-2009

y=4.2955x + 93.886
R = -0.744

Discharge planning Ideally the rehabilitation team Questions you might consider :
Discharge planning should begin as should review the patients prior to • Are heart failure patients admitted
soon as the patient is admitted. discharge, in the same way that to different wards/specialties and
Early discussion between the AHFN patients are assessed after are there differences in their
and the CHFN facilitates early myocardial infarction. readmission rate and/or length of
discharge, without a prolonged stay?
period of observation after The content of the discharge • Are patients who are admitted to
conversion back to oral medication. summary is also critical. Clear details non cardiology wards referred for
Most of this communication can of the treatment provided in a specialist opinion and how long
take place by phone or email, but it hospital and plans after discharge does this take to happen?
is beneficial for the hospital based should be included, including details
and community HFN to meet on a of monitoring and follow up
weekly basis to discuss difficult arrangements. Where the patients
management problems with the are discharged on sub-optimal doses
consultant lead, as part of the multi- of medication (e.g. ACE inhibitors)
disciplinary team. the reasons for this should be clearly
specified, as should any requests for
assistance from the GP/practice
nurses with subsequent up-titration.



4. Multidisciplinary team working

a.Case management discussions across primary-secondary care
interface - early discharge, admission avoidance - seamless service
b.Consultant lead/+GP/hospital HF nurse(s)/community HF nurse(s) etc
c. Designated care co-ordination

Multidisciplinary team working This role is often best carried out by • Are there out of hours patient
A multidisciplinary team approach is the CHFN in the patients home, but support services comparable with
useful at all stages of the patient where this service is not available the support available during
pathway. We have already alternatives include hospital based working hours?
highlighted the role of the HF team clinics run by the AHFN or practice • Is the follow-up of inpatients
in the management of in-patients. nurses trained in HF. designed to ensure that
Regular MDT meetings (ideally inappropriate readmissions are
weekly) make discharge planning Questions you might consider: avoided?
easier for the more complicated • Is there sufficiently robust • Is cardiac rehabilitation available
patients, and also facilitate discharge planning including for heart failure patients?
management of patients in the weekends so that patients are • Can patients be discharged early
community (with the potential for discharged at the earliest with confidence that they will be
avoidance of admissions). opportunity? reviewed and have renal function
• Are patients educated in their checked within a week?
Questions you might consider: condition to allow active • Do community nurses have access
• Do you have a team approach to participation in their care and are to hospital information systems to
heart failure management - if so, they confident about who to check results?
who makes up this team? contact when things start to
• Are there mechanisms in place deteriorate?
and sufficient capacity for all
inpatients with HF to be managed
by the specialist team?
• Are MDT meetings taking place Equity and inclusiveness
regularly between primary and
secondary care? It is fundamental that the AHFN's work is not confined to the cardiac
wards, nor to younger age groups. In the current situation where many
Follow up arrangements patients with HF are admitted to non-cardiac wards, it is these patients
Rapid follow up after early who have the highest mortality. It is sometimes easier for the HF teams
discharge greatly reduces the risk of to fall into the trap of delivering a very high quality service to a relatively
readmission. All patients should be small proportion of the in-patient population with HF, whilst a larger
seen within a week of discharge, group remain unsupported and without specialist input.
and this should include assessment
of fluid status (including weight) In addition all types of HF should be included in the service. Patients
and renal function. Timely with preserved ejection fraction (HFPEF) deserve identical input - and are
intervention at this stage can often often more difficult to manage.
prevent patients becoming
dehydrated and developing
impaired renal function or
alternatively rapidly regaining the
oedema they have lost in hospital.



Supportive and palliative care

5. Supportive and palliative care

a.Unnecessary admission avoidance at end of life - preferred priorities
of care
b.Palliative care involvement

Supportive and palliative, also
sometimes referred to as ‘End of
life' care helps all those with
advanced, progressive and incurable
conditions to live as well as possible
until they die. It enables the needs
of both patients and family to be
identified and met throughout the
last phase of life and into
bereavement. It includes physical
care, management of discomfort
and other symptoms and the
provision of psychological, social,
spiritual and practical support’

Experience from previous NHS
Improvement national projects,
shows that service providers often
address process issues and service
delivery before undertaking end of
life challenges. This may in part be
attributed to the difficulties
associated with the timing of and
delivery of end of life care.
• Well structured multidisciplinary NHS improvement would like to
NHS Improvement in conjunction team working is essential for acknowledge and thank all the
with the national end of life care individualised, flexible patient teams who have willingly shared
programme team published a Heart centred care their experiences for the benefit of
Failure end of life implementation • Excellent communication between others. This is an evolving
framework in July 2010. To view health professionals, patients and improvement resource which does
this document click here» carers is fundamental to a good not claim to have all the answers.
patient experience We would welcome feedback and
The key messages highlight: • Most people but not all prefer not any additional information during
• The disease trajectory for a heart to die in hospital, however this is the draft release of this document.
failure patient is not easily where many people do die.
predictable, and therefore also Please email these to
timing of EOL care plans Whilst this resource focuses on the elaine.kemp@improvement.nhs.uk
• Advance care planning supports inpatient service a large online by 30 September 2011.
patient wishes about their future collection of work covering the
care arrangements and whilst it is whole patient pathway,
sometimes a difficult subject to commissioning QIPP and quality
broach is often left too late standards can be found here»



Appendix 1 Appendix 2 The codes commonly associated
Checklist for a service review Key sources of information with heart failure are listed below.
To review local information note
The checklist below describes the There are several important sources that Heart Failure as a diagnosis can
key elements of a simple service of information and guidance for be entered as the primary or
review heart failure service providers which subsequent diagnosis. We would
should be utilised when undertaking suggest initially reviewing data with
1. Engage key stakeholders a service review: heart failure as the primary
2. Baseline the current service diagnosis.
provision • The National Heart Failure
3. Share baseline with key audit 2010 - This provides • I50.0 Congestive heart failure
stakeholders national comparative data to help • I50.1 Left ventricular failure
4. Map out the service steps clinicians and managers improve • I50.9 Heart failure, unspecified
(process map) the quality and outcomes of their • I11.0 Hypertensive heart disease
5. Prioritise and plan improvements services - click here» with (congestive) heart failure
with key stakeholders • I42.0 Dilated cardiomyopathy
6. Implementation and • NICE clinical guidance 108 - • I25.5 Ischaemic cardiomyopathy
reassessment Chronic heart failure: • I42.9 Cardiomyopathy,
7. Sustained best practice management of chronic heart unspecified.
failure in adults in primary and
• Continuous communication is secondary care - This offers
imperative at all times between all evidence-based advice on the care
key stakeholders, especially where and treatment of people with
there is patient hand over chronic heart failure, with
between heath care professionals updated recommendations on
or organisational boundaries. diagnosis, pharmacological
treatment - click here»

• NICE quality standards –
Chronic heart failure – (to be
published June 2011)
There are a series of evidence
based concise statements that
show what high-quality care
should look like.

• The British Heart Foundation
A charitable organisation
providing amongst other things
resources for both professionals
and patients - click here»

• Commissioning – NHS
Improvement quick guide to
commissioning the heart failure
whole pathway of care -
click here»


Contacts

Dr David Walker
Consultant Cardiologist, Hastings and Rother NHS Trust
and NHS Improvement National Clinical Lead
email: david.walker@esht.nhs.uk

Elaine Kemp
National Improvement Lead, NHS Improvement
email: elaine.kemp@improvement.nhs.uk

Sheelagh Machin
Director, NHS Improvement - Heart
email: sheelagh.machin@improvement.nhs.uk

NHS
CANCER
NHS Improvement

DIAGNOSTICS

HEART

LUNG

STROKE

NHS Improvement

NHS Improvement’s strength and expertise lies in practical service improvement. It has over a
decade of experience in clinical patient pathway redesign in cancer, diagnostics, heart, lung and
stroke and demonstrates some of the most leading edge improvement work in England which
supports improved patient experience and outcomes.

Working closely with the Department of Health, trusts, clinical networks, other health sector
partners, professional bodies and charities, over the past year it has tested, implemented, sustained
and spread quantifiable improvements with over 250 sites across the country as well as providing
an improvement tool to over 800 GP practices.

NHS Improvement
3rd Floor | St John’s House | East Street | Leicester | LE1 6NB
Telephone: 0116 222 5184 | Fax: 0116 222 5101

www.improvement.nhs.uk
©NHS Improvement 2011 | All Rights Reserved
Publication Ref: IMP/comms019 - June 2011

Delivering tomorrow’s
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A guide for review and improvement of hospital based heart failure services

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