Structured services for the management of acute decompensated HF (ADHF)
The focus of the work of the NCP HF in the acute setting to date has been to establish specialist hospital services for patients presenting with acute decompensated HF including programmatic post discharge follow up.
There are currently 12 sites operating the NCP HF structured heart failure model. These active sites are: Our Lady of Lourdes Hospital - Drogheda, Beaumont Hospital, Mater Misericordiae Hospital, Connolly Hospital – Blanchardstown, Cavan/ Monaghan General Hospitals, St. James’s Hospital, Adelaide and Meath Hospital – Tallaght, St Vincent’s University Hospital, Wexford General Hospital, University Hospital – Limerick, Sligo General Hospital, University College Hospital – Galway.
These sites have introduced a structured specialist hospital service for patients presenting with ADHF, including programmatic post discharge follow up. They deliver an integrated service through the Model of Care for Heart Failure developed by the NCP HF, which follows international best practice.
Successful pilot projects on virtual clinics, which support General Practitioners to manage heart failure patients in the community have been carried out by the NCP HF. An integrated care project on providing clinical nurse specialists in the community to support GPs to manage heart failure patients has also been commenced in one area.
Virtual Consultation Service
Appropriate use of specialist advice and avoiding need for hospital and outpatient attendance has been a key target of this programme. Recognising that giving GPs access to senior specialist advice in a structured and timely manner will avert need for OPD and emergency department referral led to the development of the idea of virtual consultation (VC) where GPs, practice nurses and specialist staff interact using webconference technology to discuss and manage cases collaboratively. This also allows simultaneous education for the group.
The Clinical Strategy & Programmes Division of the HSE has funded St. Vincent’s University Hospital to implement and evaluate an innovative demonstrator project in the community – General Practice Virtual Consultation Service for heart failure patients. This is an 18 month project which commenced at the end of 2016 in the Carlow – Kilkenny area.
This allows for direct specialist diagnostic access for patients discussed at VC, where appropriate. The VC service should lead to a reduction in the need for onward referral to routine outpatients, leading to a reduction in unnecessary travel for many. Additional Funding has been requested to extend this service to IE area.
Prevention Programme - Screening for Asymptomatic Left Ventricular Dysfunction in the Community
This service, also referred to as STOP HF / STOP HF Midlands builds on both the well established Midlands Diabetes Scheme and the STOP HF programme. In this service patients receive a natriuretic peptide test as part of their follow up and echocardiography where indicated based on this. In this service it was demonstrated that in the group that required echocardiography there was excellent control of risk factors, which were comparable to the intensive control arms of major diabetes trials. However despite this it was found that 32.8% had evidence of ventricular dysfunction on echocardiography.
A recent review of the data has demonstrated that GPs are also acting on the information received. 47% of those patients who received echocardiography had a reduction in their NTproBNP over 2.5 years. Baseline ACE inhibitor/ARB use was 62% and 40% had these increased or the agent added following the STOP HF intervention.
1,536 patients were assessed in 2016. For those seen in the hospital setting echocardiography is performed on same day as required.
Evidence to date shows this will reduce hospitalisations and prevent onset of HF over follow up. It develops a cross programme approach to common risk factors and provides a platform for management of cardiovascular disease.
Community New Diagnostic Clinic (Gorey/ Wexford/ SVUH Group)
This diagnostic clinic, established under the programme, provides direct access for general practitioners to brain natriuretic peptide (BNP) testing and echocardiography in the community with remote specialist advice on echocardiography results and specialist review of patients in the community when required. The plan - to assess 200 patients over 12 months – 204 referrals were received in 2016.
Patients are seen within 4 weeks of referral for echocardiography and review. This leads to improved access for patients to diagnostics and specialist advice, appropriate referral and early diagnosis of their underlying condition and reduced costs in the diagnostic process. It has resulted in a dramatic (63%) reduction in clinic reviews and a 37% reduction in need for echocardiography in the diagnostic process for HF.
Heart Failure Integrated Care Project in the Community
The project has just recently commenced with appointment of 2 Integrated Care Clinical Nurse Specialists for Heart Failure in the community in Carlow/ Kilkenny. This integrated care project will demonstrate integration between primary care, secondary care and the hospital group. The project will leverage existing ehealth technology and strengthen patient self care with enhanced nursing supports (via the dedicated CNS posts) and training for GP/GP practice staff and patient self care training.
The specialist HF consultant from the tertiary hospital will attend one outreach clinic and four virtual clinics per month. The specialist acute based service will also provide same day advice to general practice for emerging deterioration of patients and email consultation for rapid but non urgent decision support to general practice.
The vision of the Integrated HF programme is that individuals with HF in Ireland should reach their maximal health and quality-of-life potential through the prevention, early detection and effective assessment, management and use of treatment pathways for their condition, in line with the objectives of the NCP HF; HF Model of Care.
Medicines Management Interventions in Cardiovascular Disease
In 2016 222 patients underwent medication management. Interventions carried out by the HF/HBT Pharmacist from SMH Unit covering both Gorey and Midlands patients and included: Direct patient counselling, adherence assessment and pharmaceutical care. Contacting patients’ pharmacy to clarify medication history and previous history.
Group medicines management education sessions, including education on heart failure medicines, were provided to patients at risk and with newly diagnosed heart failure by pharmacist and clinical nurse specialist. Web conferencing involving multidisciplinary team in hospital and community to rationalise medications and reduced potentially inappropriate prescribing was trialed on ongoing basis.
Advising medical/nursing prescribers regarding optimal therapy or inappropriate therapy Education of new cardiology registrars regarding potentially inappropriate medicines in heart failure. Education of new cardiology registrars regarding new medications for heart failure and medicines information queries. Development of new medicines focused Pharmacist and General Practitioner information booklets. Development of new medicines focused patient information booklets, including quality assurance on language use by NALA.