NHSImprovement-Heart HEART Pathwaysforheartfailurecare ...

NHS Improvement - Heart

Pathways for heart failure careMaking improvements in heart failure services:

Final reports from the national pilot sites

(2008/10)

NHSNHS Improvement

HEART

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CANCER

DIAGNOSTICS

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Heart

3Pathways for heart failure care: Making improvements in heart failure services: Final reports from the national pilot sites

Foreword

Introduction

Heart failure: Diagnosis and management

• Better management of heart failure in general practice - Central Manchester

• Improving the acute heart failure pathway - West Hertfordshire

• Reducing length of inpatient stay through early diagnosis - Essex

• An integrated model of heart failure care - East Riding of Yorkshire

• Improvement of heart failure diagnosis and management in NorthStaffordshire and Stoke

• Heart failure self management - Bassetlaw

• Developing community heart failure services - Southwark

Heart failure: End of life

• Promoting access to end of life care provision and choice - Brent

• Enhancing end of life care for heart failure patients - Northampton

• Supportive and palliative care for heart failure - Sussex

• Development and implementation of ‘symptom control guidelines forpatients with heart failure up to and including end of life’ - NorthLincolnshire and Goole

• Improvements in palliative care – referral and pathway development -West Surrey

NHS Improvement Heart Failure Team

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Contents

4 Pathways for heart failure care: Making improvements in heart failure services: Final reports from the national pilot sites


Foreword

Heart failure is the end result of a number of conditions that affect the

heart and lungs. Although the prognosis has improved significantly in the

last decade, it remains a syndrome that produces a great deal of misery

and dependency. Because it is commoner in older patients it is often only

a part cause of their overall disability and the need to consider their other

ailments complicates the pathway significantly.

For this reason holistic care of heart failure patients is not

straightforward. There may be a multitude of agencies involved, and

carers are often central. The relationship between clinical staff in primary and secondary care is of

prime importance.

The project reports in this document detail a variety of approaches to improving the management of

heart failure both in hospital and in the community. For the first time there have been specific projects

centred on the management of end-of-life and the use of palliative care services, an aspect that many

good heart failure services have struggled with in the past.

Other projects concentrate on aspects of heart failure, with a strong theme of working with patients

and carers to encourage their knowledge and understanding of the condition and to help them make

informed choices.

Heart failure is undoubtedly an area where better care may result in lower costs and these projects

exemplify that, showing reductions in admissions, length of stay, readmissions, and more appropriate

deaths at home. As a result of these projects, work is underway that shows the potential to release

substantial savings (overall £67M by reduction in length of stay, £13.7M through the introduction of

BNP and £49M through admission avoidance).

In the current financial environment it is tempting to think that constructive service development is

impossible. These projects show otherwise. The value of dedicated heart failure teams working with

the more generic community services is clear.

Dr Mark Dancy

National Clinical Lead for Heart, NHS Improvement



Heart failure is a clinical syndrome caused by areduction in the heart’s ability to pump blood aroundthe body. The prognosis is poor and the survival ratesare worse than for some cancers. The London HeartStudy (updated 2005) shows 38% mortality within thefirst year of diagnosis.

In the UK heart failure affects around 1% of thepopulation, increasing steeply with age to about 7% inmen and women over 75-84 years and 15% of thoseaged 85 and above. Due to the combined effects ofimproved survival following a heart attack and anaging population the number of heart failure patientsis due to rise over the next 20 years.

Heart failure has a significant impact on patients andNHS resources with an estimated cost to the NHS of£625 million per year made up of prescription costs(£54m, IMS medical data index 2002), GP/communitynurse costs (£105m; Health stats quarterly 1999),hospital inpatient costs (£379m, HES 08/09), andoutpatient costs (approx £51m of which £37m isoutpatient investigations, BHF online stats).

• According to hospital episode statistics (HES) data, in2008/09, there were 53,164 HF emergencyadmissions leading to 740,697 bed days, 2% of allinpatient bed days.

• The National Heart Failure Audit 2008-09 states thatmortality rates are high with a 10.5% inpatientmortality and that only 6% of those that died hadbeen referred to palliative care.

• Heart failure readmission rates are among thehighest for common conditions, the National Heartfailure audit shows a 17.5% readmission rate, whichis probably an underestimate nationally and has beenestimated as high as 50% over three months (NHSModernisation Agency report, 2004).

• Heart failure is one of the largest sources ofemergency admissions and occupied bed daysaccounting for 5% of all emergency admissions and90% of all heart failure admissions are emergencyadmissions (HES data 2008/09).

• Again, the national Heart Failure audit shows thatonly 44% of heart failure patients are admittedunder cardiology and it is probably a significantlylower proportion in hospitals not taking part in theaudit.

Introduction

• Whilst 68% of NHS Trusts have registered to takepart in the National Heart Failure Audit, only 43%have submitted any data.

In March 2008, NHS Improvement invitedorganisations to work in partnership on projectsdedicated to improving the heart failure pathway, upto and including end of life. Projects were submittedfrom acute trusts and PCTs, as well as cardiac andstroke networks. Whilst our primary aims are toimprove patient experience and outcomes and removeinefficiencies from the process, it is important that indoing this we also achieve a reduction in bed days,admissions and interventions, and so reduce theburden on the health service.

Every new project raises new challenges, but therehave been particular challenges for the projectsdeveloping end of life pathways for heart failurepatients, and these led to delays in getting many of theprojects off the ground. The slow start was due in partto building new relationships with palliative care andthe end of life team members, in part to a lack ofclarity around when end of life care should begin inheart failure, and also the complexity of commissioningan end of life service for heart failure patients. Thatthese projects have all now completed and havedeveloped models that will benefit and inform otherlocalities as they begin to look at their services, is atribute to the persistence and hard work of the projectteams.

The projects, due to last between one and three years,were launched in September 2008. The scope, scaleand diversity of the successful applications can be seenin the following summary.

NHS Improvement supports project sites, individuallyand collectively, in a number of ways, including peersupport meetings, site visits, access to national clinicalleads, access to the NHS Improvement System,education and training, and through sharing andpublishing helpful resources. Visit our website atwww.improvement.nhs.uk/heart/heartfailure for accessto online resources promoting learning and sharingfrom these and other areas of improvement work.

Heart failure: Diagnosis and managementThe 2008/10 projects:



Better management of heart failure in generalpractice - Central Manchester

Aims• To improve the quality of care

provided in GP surgeries to patientswith heart failure

• To improve the well being ofpatients with heart failure

• To improve such patients’satisfaction with their care

• To see if these quality improvementsin primary care would result in areduction in heart failure-relatedhospital admissions.

A Local Enhanced Service (LES) schemewas developed to encourage practicesto train at least one GP and one nursein the management of heart failure ineach practice, and then to continuallyaudit their performance in heart failuremanagement.

Early agreement with the PracticeBased Commissioning group andPrimary Care Trust ensured managerialsupport. Developing the educationpackage has helped considerably byearly involvement and enthusiasm oflocal cardiology consultants and theUniversity Department of Cardiology.

Six GP practices completed theaccreditation programme andimplemented the local enhancedservice at their practices. Hospitaladmission data was collected tomonitor improvement.

Patients needed to be identified onpractice systems with an accuratediagnosis of heart failure. Aneducation and accreditationprogramme was designed for primarycare clinicians to ensure a high level ofknowledge and skill amongparticipating practices.

OutcomesIt is clear from the graphs above thatimprovement in patient managementbegan during the period when theenhanced service was being discussedand the criteria of good managementwas agreed with interested practices.

This improvement, however, increased once the service commenced and thedifference between those practices taking up the service and those who did nothas been maintained.

ConclusionThe results indicate that practices inthe local enhanced service havereduced their own rate of hospitaladmissions for heart failure by 37%;and now have 43% fewer hospitaladmissions compared to the rest ofcentral Manchester as a whole leadingto a total annual saving of £77,836 forthe six practices.

Number of emergency readmissions per four quarter period(Readmitted within four weeks of primary episode, per 1,000 population)Vs % LES introduced

Number of admissions for heart failure per four quarter periodVs % LES introduced

43% reduction in hospital admissions leading to savings of almost£78,000 in one year for the six practices involved.

ContactsProject Leads: Luke Coleman and JoanneLangton, Manchester Primary Care Trustand Greater Manchester and CheshireCardiac and Stroke [email protected]@gmccardiacnetwork.nhs.ukClinical Lead: Dr Ivan Benett – GeneralPractitioner with a Special Interest(GPwSI) in Cardiology

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Improving the acute heart failurepathway - West Hertfordshire

AimsTo develop and put in place a robustsecondary care heart failure pathwaythat integrates with a discharge policyand the community heart failureservice.

This project to redesign the secondarycare acute pathway and speed updiagnosis of heart failure wasundertaken to coincide with theopening of the new Acute AdmissionsUnit and the transfer of acute servicesto Watford General Hospital.

The new integrated pathway toinclude urgent serum NP (natriureticpeptide) testing on admission, rapidaccess to echo and daily cardiologyward rounds was implemented and itsimpact measured from April 2009 toMarch 2010.

Serum NP testing allowed for easyidentification of possible heart failurepatients admitted under otherspecialties, and ruled out thosewithout heart failure, reducing thetime the heart failure specialist nursehad previously spent searching forpatients on other wards and alsoreducing unnecessary echos onpatients with other causes ofbreathlessness. The proportion of heartfailure patients seen by a member ofthe heart failure team and who hadtheir diagnosis confirmed byechocardiogram before discharge rosewithout increasing nurse hours or echodemand, due to the ability to identifyand prioritise patients from their serumNP levels.

OutcomesAnalysis of admissions and length of stay showed little significant change.Although the proportion of patients receiving an echo during their inpatient staydoubled from less than 30% to 66%.

The biggest impact was found to be on readmission rates with reduction in totalreadmissions of 42% and reduction in <30 day readmissions of 57%.



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ConclusionThe improvement in the patientpathway and the co-ordination ofhospital and community servicesreduced readmissions by half. Noreductions were seen in length of stay,but more was done for the patientsduring their admission (e.g. more hadtheir diagnosis confirmed by echo andwere seen by a specialist). Thereduction in readmissions represents asaving of £69,000, and the cost ofproviding serum NP testing onadmission for one year came to£38,800 giving an overall saving£30,200.

ContactsProject Lead: Candy Jeffries,Bedfordshire and Hertfordshire Heartand Stroke Network [email protected]

Clinical Lead: Dr John Bayliss,Consultant Cardiologist, West HertsHospital NHS Trust

Cost of bed days saved = £69,000. Cost of providing Serum NP= £38,800. Overall saving of £30,200 in one year.

Readmissions



Reducing length of inpatient stay through earlydiagnosis - Essex

AimsTo reduce average length of stay forprimary diagnosis heart failureadmissions by more than two days byimproving the pathway across primaryand secondary care.

Heart failure pathway mappingrevealed two main areas forimprovement:• Identifying and locating patients

admitted with heart failure so thatthe heart failure team could assessthem

• Timely confirmation of the diagnosisby echo to prevent delayeddischarge and facilitate onwardreferral to the community service.

A new pathway was agreed betweencommissioners and providers and aservice level agreement finalised, thepathway was aimed at identifyingpatients in hospital, ensuring theywere on the optimum treatment, andthen discharging the patient back tothe community with a managementplan. Multidisciplinary team meetingswere set up to ensure that there wasgood communication between primaryand secondary care.

Serum natriuretic peptide testing(NTproBNP) was introduced to theMedical Assessment Unit (MAU) at theacute trust to aid identification ofheart failure patients and prioritiseecho.

OutcomesUsing the new pathway to speed updiagnosis, treatment and discharge tothe community service, Basildon andThurrock University Hospital havereduced bed days by a total of 1,249per year saving £312,250 on bed days,although the cost of increased nursesat the rate of £50,000 per whole timeequivalent specialist nurse with oncosts, must be set off against that.

ConclusionEarly identification of heart failurepatients enables rapid confirmation ofthat diagnosis, speeds up treatmentand reduces length of stay.

ContactsProject Lead Alison Springett,Essex Cardiac and Stroke [email protected]

Clinical Lead: Dr Gautam Chajed, PCTCardiovascular Lead, Essex.

Median length of stay reduced from 12 to 4 days releasing 1249 beddays per year at a cost saving of £312,250

Length of stay for heart failure. Basildon and Thurrock University Hospital

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An integrated model of heart failure care -East Riding of Yorkshire

AimsTo design and implement anintegrated model of care for heartfailure in the community incollaboration with other keystakeholders and improve heart failurediagnosis and treatment.

The PCTs Design and Innovation Teamhave developed and adopted a threestep workshop approach to help agreea new commissioning model alongwith local General Practitioners (GPs)and Practice Based Commissioning(PBC) groups. We have also usedInvestment Analyser software to assessthe heart failure project and anothertool - Scenario Generator (SG) - tomodel the impact of implementingserum natriuretic peptide testing andthe savings potential of three differentscenarios. The scenario generatorpredicted cost savings of a minimumof £85,000 per year.

Following this analysis and given thepotential financial savings predicted,NTproBNP testing was launched1 September 2009.

In the future, as a result of theworkshops and through PBC webelieve that GPs will now have aclearer focus on the services they wishto change and commission andbecause of this will become moreengaged and work closer with thePrimary Care Trust and commission asustainable, efficient, patient-centredservice.

OutcomesGood engagement of generalpractitioners (GPs) in thecommissioning process led to good GPuptake of the new test and directaccess echo.

As a result of the workshops, GPs havehad an opportunity to be exposed tocommissioning and this process hasencouraged them to be more involvedin changing services and in thedevelopment of business models(something they will need to do moreoften as they become the maincommissioners.)

Data collated within the first sevenmonths (2009/10), showed that 351patients or 45.24% of the 776patients tested in primary care wereunlikely to have heart failure. Analysisof the first three months of data(2010/11) shows a reduction in referralto out patients of 15%.



Based upon the test activity data, wehave modelled the expected impact onCardiology outpatient referrals(reduced by between 550 and 770 peryear) and therefore the possiblesavings that will be achieved between£66,000 and £111,000 per yeardepending on pathway, the first sevenmonths of data supports savings in thisregion for the full year.

ConclusionThe use of NTproBNP as a negativediscriminator to exclude HF in primarycare allows for more appropriatereferral of patients to a Cardiologist.

As a commissioning organisation thispathway for the diagnosis andmanagement of heart failure patientshas been subsequently included in ourQuality, Innovation, Productivity andPrevention (QIPP) programme as itdemonstrates productivity and qualityin primary care.

Predicted Saving: Introduction of Serum NP testing to the diagnosticpathway on target to save between £66,000 and £111,000 in thefirst year.

ContactsProject Lead: Stuart Gill, East Riding ofYorkshire Primary Care [email protected]

Clinical Lead: Dr Mark Hancocks,General Practitioner



Improvement of heart failure diagnosis andmanagement in North Staffordshire and Stoke

AimsTo improve diagnosis and management ofpatients with left ventricular systolicdysfunction across North Staffordshire andStoke.

Following a disappointing HealthcareCommission report on heart failureservices for patients in NorthStaffordshire and Stoke in 2006, it wasdecided to use it as an opportunity toboth assess the service thoroughly andalso address any shortcomings revealedby that assessment. A thorough audit ofall aspects of heart failure care andknowledge across the health economywas therefore undertaken.

The results of those audits showed:• Physicians diagnosing heart failure

patients have educational needswith regards to changing criteria forrobustly diagnosing heart failure

• The use of echocardiography is sub-optimal both on an out andinpatient basis

• Physicians caring for heart failurepatients have educational needswith regards to current best practice

• Aggressive management of co-morbidities (COPD, AF) may preventreadmissions

• The specialist heart failure nurseservice is underutilised forappropriate, high risk patients andhas too many referrals for patientswho are inappropriate for the service

• Patient understanding andinvolvement in their chronic diseasemanagement is sub-optimal andneeds to be improved

• The palliative and terminal careneeds of our heart failure patientsare poorly addressed

• The current referral form for thespecialist heart failure nurse serviceis not fit for purpose.

OutcomesAs a result of this work, the UniversityHospital of North Staffordshire (UHNS)are considering the increase of specialistinvolvement with heart failure, and a

greater an emphasis has been placed onquality delivery in all areas.

The collection and dissemination of theaudit findings were part of a two yearlong programme of education that hasalready yielded mortality benefits to ourpatients and has facilitated datacollection to fuel the next phase ofservice improvement (see diagramsabove).

ConclusionsThe importance of collecting good localdata cannot be emphasised too strongly.The availability of such data has beeninstrumental in facilitating change withinthe pre-existing structure of heart failuremanagement at UHNS. It has also helpedhighlight the need for more specialist

involvement in heart failure care(suggested within the most recent NICEguidelines) and provided guidance onwhere best to achieve the next majorgains in heart failure care delivery withinour health economy. Our first projectleading on from the audit is to improvethe pathway for end of life care in thecommunity.

ContactsProject Lead: Sarah Crawford-Thomas,Shropshire and Staffordshire Heart andStroke [email protected]

Clinical Lead: Dr DuwarakanSatchithananda, Consultant in HeartFailure, University Hospital NorthStaffordshire NHS Trust

Inpatient mortality against speciality on discharge

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Inpatient mortality from 2007/8 (i.e. before the re-launch of the heart failure servicein 2008/9) and from 2009/10. Gen Med = heart failure patients discharged underthe care of general physicians), Cardiol = heart failure patients discharged under thecare of the cardiologists, National = 2009/10 mean in patient mortality from theNational Heartfailure audit 2009/10, HF Cardiologist = mortality fromcommencement of employment of HF cardiologist in 2008-2010).

Length of stay for index heart failure admission 2009/10 and percent readmittedwithin 30 days of discharge with a further primary discharge diagnosis ofheartfailure against ward on discharge (Cardiology Wd = cardiology ward, Gen Med= general medicine, Acute Med = short stay acute medical ward)

Heart failure self management - Bassetlaw

AimsThat patients with a new diagnosis ofheart failure confirmed by echo andwho are registered with a BassetlawGP, have access to structured groupsessions on education about theircondition to empower them andpromote self management.

A programme of education and selfmanagement sessions for patientsnewly diagnosed with heart failure,and their carers, was developed toinclude the following topics:• What is heart failure?• Fatigue awareness• Safe exercise - including practical

sessions of Tai Chi• Medicine management• Diet• Choice around end of life and

advance care planning• Symptom management• Information on accessing services

from adult social care.

From March to December 2009, 55patients, and 35 carers, attended thecourses and were asked to completesurveys. Data was collected onadmissions, length of stay andinterventions and compared to thosewho did not attend the sessions. Manypatients, carers and health careprofessionals were also interviewed toinform a Social Return on Investment(SROI) analysis and report.

Outcomes1. The SROI analysis showed that for

only a modest investment, therewere considerable benefits whichwere calculated as a £2.65 return forevery £1 invested.

2.The structured education gavepeople the confidence to selfmanage; they felt in control andwere less likely to contact their GP(predicted 25% reduction in GPvisits)

3.All patients reported an improveddiet as a result of the educationreceived.

4.70% of patients felt more confidentto undertake regular exercise.

5.Patients had increased knowledgeof medicine management and whento trigger a titration review.

6.Patients were better managedleading to reduced hospitaladmissions. Those that attended thesessions almost halved their rate ofadmission to hospital in the fourmonths after attendance whencompared to newly diagnosedpatients who did not attend thesessions (from 7% admission rate to4%, - a significant drop despite thesmall numbers and short timeperiod). This reflected the consultantcardiologist’s view of the impactobserved since the patient educationhad started.

7.Patients’ medication was titrated tooptimal levels more often and fewerpatients needed district nurse carepackages for oedema management.

8.Patients were better informed aboutcaring for themselves and it waspredicted that fewer patients wouldrequire Local Authority home carepackages in the future.



ConclusionThose that attended the sessions weremore knowledgeable about heartfailure and its management, weremore aware of healthy lifestyles, theservices available for them and how toaccess them. The self-managementpart of the programme was reflectedin a reduced need for interventions.Overall, patients who attended thiscourse were less likely to needadmission to hospital. (from 7%admission rate in the six monthspreceding attendance to 4% in the sixmonths after attendance).

ContactsProject Lead: Heather Towndrow,Bassetlaw Primary Care [email protected]

Clinical Lead: Kathleen McGunigal,CHD Matron.

SROI return of £2.65 for every £1 invested.Predicted saving: 35% reduction in GP appointments.



Developing community heart failureservices - Southwark

AimsTo establish a community heart failureservice for the people of Southwarkand to ensure that the service suits theblack and ethnic minority (BME)population.

The Southwark community heartfailure project was set up bySouthwark Health and Social Care(SH&SC), funded jointly by them andGuy’s and St Thomas’s (GSST). It has asits specific aim, ensuring that theservice offered suits black and minorityethnic (BME) groups as current datasuggests that they are under-represented in heart failure out-patientclinics. It was generally agreed thatclinics closer to home would helpattendance of all groups.

In 2008, the Southwark communityheart failure nurse addressed blackchurch leaders and asked them toencourage their patients to attend anyclinic appointments and take theirmedication.

Community clinics were set up in areaslikely to attract better attendance andtelephone support for patients offeredin addition to face to face clinicappointments.

A patient survey conducted in July2010 showed that BME patients wereslightly more satisfied with the servicenow provided than their whitecounterparts, with BME patientsscoring 100% satisfaction and whitepatients 97% for overall satisfactionwith the service. In the survey, manyof the free text answers as to whatpatients particularly liked about theservice, related to their ability to obtainadvice and reassurance by phone.

Two GPs are acting as champions forheart failure care and detection in thecommunity, running education eventsfor GPs and practice managers, whichinclude encouraging them to enablecomparison of their heart failureregisters with their admissions forheart failure.

Outcomes• New to follow-up ratio at King’s

College Hospital outpatient heartfailure clinic reduced from 1:5.8down to 1:5.

• The actual numbers of patients onthe QOF heart failure registersincreased by 119 patients from2007-08 (1,168) to September 10(1,287). About a quarter of thisincrease was due to comparison ofnine individual practice heart failureadmissions to the practice registers.

• The median length of stay reducedfrom nine days to seven days.

• Seven fewer emergency admissionsin six months with heart failure asprimary diagnosis from 33 randomlyselected patients under the care ofthe Southwark community heartfailure service with one year’s worthof data. Six of these patients diedwith an average age of death of77 years.

• Reduction in admissions if replicatedacross patch, predicted to savebetween £158,000 and £261,000 inone year against the additional costof running the community service of£105,000. Leaving net savings of£53,000-£156,000.

• The project has also resulted in asurvey on non-attenders (DNAs) andthe subsequent introduction oftransportation which brought theDNA rate down by 35%. This hasnow been included in the case forfurther funding.

• The specific learning on workingwith the BME population will helpwith future service development.

• This project has produced strongevidence on the positive financialimpact of a community heart failureservice and has been crucial inproviding the information neededfor a strong business case tocontinue future funding for theservice.

ConclusionThe introduction of a community heartfailure service specifically targetingBME groups in this diverse populationhas reduced secondary care follow-upclinics appointments, DNAs,emergency admissions and medianlength of stay; despite a larger numberof patients having been identified onGP registers.

ContactsProject Lead: Roslind Harper,Southwark Health and Social [email protected]

Clinical Lead: Helen Williams,Consultant Pharmacist.

Predicted saving: After costs, this service is predicted to save morethan £53,000 per year in saved admissions and a 35% reductionin DNAs.

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Heart failure: End of life

Promoting access to end of life care provisionand choice - Brent

The 2008/10 projects:

AimsTo develop an end of life heart failurepathway within a culturally diversecommunity.

A new end of life pathway wasdeveloped, to include greater liaisonwith access to community palliativeservices, and documentation aroundadvance care planning and an end oflife care trigger tool have beendeveloped. The trigger tool is availablein the heart failure resource library onthe Pathways for Heart Failure Careweb page.www.improvement.nhs.uk/heart/heartfailure

An audit of the service wasundertaken before and afterimplementation of the new pathway.

Outcomes• Improved patient choice at the end

of life.• Improvements in education and

training for both heart failure andpalliative care nurses through jointworking and to extend educationand training (as necessary) to otherhealth care professionals.

• Reduction in avoidable re-admissionsto hospital via use of other servicessuch as hospice-at-home, hospiceservices and community palliativecare teams.

• Improvements in the quality of theservice provided to patient/carers.

• Provision of a holistic heart failureservice that spans referral to end oflife care.

This project won NHS BrentCommunity Provider Services‘Achievement Award’ and wasawarded joint first prize with districtnursing.

ConclusionSignificant increases in the numbers ofpatients who were referred forpalliative care and who died in theirpreferred place of care were recorded.There were also significantly fewerdeaths in hospital, but the full financialimpact of giving patients the choice ofplace of care is unclear. What isincontrovertible is that patients wereable to have a real choice of place ofcare and that their experience wasgreatly improved by this.The project has achieved its originalobjectives to improve access topalliative care services for heart failurepatients and ensure that equitablereferral and assessment processes arein place throughout the LondonBorough of Brent.

ContactsProject Lead: Temo Donovan,North West London Cardiac and [email protected]

Clinical Lead: Dr Mark Dancy, ConsultantCardiologist, North West LondonHospitals NHS Trust


Improved access to palliative care services.Improved choice at end of life with more patients dying in theirpreferred place of care.




Enhancing end of life care for heart failurepatients - Northampton

AimsTo give clear guidance for healthprofessionals treating patients withadvanced heart failure, ensuring earlyassessment of palliative care needs androbust referral and treatmentprotocols.

A new supportive care pathway wasdeveloped and launched in October2009. This pathway includes a formalassessment for patients thought to bereaching the end of life, and clearguidelines, protocols and referralcriteria including the use of prognosticindicators.

OutcomesThe service now ensures that all heartfailure patients are identified and theirpalliative care needs assessed within48 hours of their admission. There areformal links with the palliative careteam at the hospital. The generalmedicine team/directorate haveapproved the pathway and generalphysicians refer those heart failurepatients that are not admitted under acardiologist.

These discussions and assessments aredocumented on a care plan and amanagement plan is produced andsent to GPs, patients, the out of hoursservice and East Midlands AmbulanceService(s) on discharge. If the patienthas identified a preferred place of carethis is acted upon and appropriatearrangements are made. There areformalised links with the communityteams including Macmillan, MarieCurie, Health and Social Care,Hospices and Hospice at Home.

The assessment record is to include thehospital’s PPC documentation/form.

ConclusionThe original view of early identificationof patients to include on the pathwayhas proved more difficult and theproject has concentrated on thosepatients nearer the end of their life,but this process has been made muchsmoother and patient experience andquality of care has improved, and issupported by patient survey results.

ContactsProject Lead: Gill Dunn,East Midlands Cardiac andStroke [email protected]

Clinical Lead: Dr Dave Riley,Consultant in Palliative Medicine,Northampton General Hospital.

Supportive and palliative care for heartfailure - Sussex

AimsTo develop a strategy to provide anintegrated supportive and palliativecare heart failure service across theprimary and secondary care interface.

A new integrated pathway, palliativecare for heart failure patients wasdeveloped and is now provided acrosssettings, using the local hospice (StMichael’s) for education, respite care,day therapy and symptom control.An intravenous (IV) diuretic protocolhas been developed, for use inprimary, secondary and hospice care, ithas proved very helpful in secondarycare and is now being piloted in thehospice setting for patients who preferto be admitted there for symptomcontrol.

Cross speciality education sessions areongoing, and staff from St Michael’scome to the Conquest Hospital forpractical experience in managingpatients with heart failure.

A ‘buddy system’ support group wasalso started.

OutcomesUsing the hospice for the heart failureeducation sessions has helped toremove some of the perception that ahospice is a place where you go to die.As a result, patients have been muchhappier about using some of the otherfacilities provided by the hospice, suchas complementary and day therapies.

A protocol for giving continuous IVFurosemide was developed andinitiated on a single ward and its’ useassessed on 20 patients. The report isavailable in the heart failure resourcelibrary on the Pathways for HeartFailure Care web page.www.improvement.nhs.uk/heart/heartfailure

ConclusionThe patient experience has beengreatly improved by introducingpatients to the hospice at an earlystage and patient surveys havesupported this.

In the provisional assessment of theprotocol for continuous IV Furosemideinfusion appeared safe and effective inan elderly cohort of patients withdecompensated heart failure. Furtherevaluation is underway with a view toformal publication. Our intention, oncefully validated, is to introduce theprotocol, under the supervision ofspecialist heart failure nurses, to non-specialist wards and to the MedicalAdmission Unit.



ContactsProject Lead: Toni De Freitas,Sussex Heart [email protected]

Clinical Lead: Dr Hugh McIntyre,Consultant Cardiovascular Physician.

Change in the way a hospice is used and viewed by patients.IV diuretic protocol developed.



Development and implementation of ‘symptom controlguidelines for patients with heart failure up to andincluding end of life’ - North Lincolnshire and GooleAimsTo develop and implement symptomcontrol guidelines for heart failure(focusing on end of life needs).

General Practitioners and other healthcare professionals were surveyed at thebeginning of the project to ascertaintheir level of confidence, knowledgeand ability to manage symptoms inpatients with heart failure up to andincluding the end of life.The survey showed that clinicians’confidence in this area was low, and amultidisciplinary team was set up todevelop comprehensive symptomcontrol guidelines for use by cliniciansacross primary and secondary care.

Symptom control guidelines developed.

OutcomesThe guidelines have been launchedand are now available in the heartfailure resource library on thePathways for Heart Failure Care webpage at:www.improvement.nhs.uk/heart/heartfailure

ContactsProject Lead: Louise Bevington,North Lincolnshire and Goole HospitalsNHS Foundation Trust,[email protected]

Clinical Lead: Dr Ann Morris,Medical Director

Improvements in palliative care – referral andpathway development - West Surrey

AimsTo develop and put in place a protocolfor referral and on-going managementfor end stage heart failure and todevelop within this an out of hours(OOH) pathway that will assist patientswho do not want to be admitted intohospital, to follow their preferredpathway and priorities of care.

A daytime pathway for urgent careand an out of hours pathway weredeveloped and implemented, givingcover in hours from the heart failurespecialist community nursing as well asdistrict and community nursing teams.During out of hours, a single numbercan be accessed via the acute hospitalswitchboard number to the OOHcommunity nursing team who willtriage the call appropriately.

Discussions are currently being heldwith South East Coast Ambulancearound a proposal to develop aninformation sharing protocol to shareinformation of patients that are underthe care of the palliative care team.This will assist in paramedic staffhaving access to information of thepatients preferred priorities of care tofacilitate care on the appropriatepathway.

A programme of education for healthprofessionals involved in the newpathway is in place and has been wellreceived.

Outcomes• Increased proportion of patients /

families that have had opportunityto discuss end of life issues (from21% to 64%).

• Increased proportion of patients thathave their Preferred Place if Carerecorded or an Advance Care Plan inplace (12% to 55%).

• Increased proportion of patientsdying in their preferred place of care(7% to 55%).

• Increase in the awareness of placingheart failure patients on the GSFregisters amongst GP practices dueto ongoing education andawareness sessions.

• An out of hours pathway has beendeveloped for patients.



ConclusionImproving communication, educationand training for generic out of hoursdoctor services, community nursingservices and the ambulance servicemeans that 24/7 support can be givento heart failure patients at the end oflife, giving real choice about place ofcare and preventing unnecessaryadmissions.

ContactsProject Lead: Mumtaz Parker,Surrey Heart and Stroke [email protected]

Clinical Lead: Matt Loveridge,Macmillan Community Team [email protected]

Patient, relative orcarer contact the

communitynursing team

Patient, relative orcarer contact the

ambulanceservice

The call is triaged/assessed by the

communitynursing team

The EDC will advisecrew if the patient

is on the GSFregister

On arrival to the patient,appropriate documentationis referred to re preferred

priorities of care

If the call is not lifethreatening, the team

will visit and assessthe patient

Seek medical advicefrom OOH hospice or

Macmillan serviceprior to visit

Thames Doc maybe called if it is

felt tht the patientnedds medical input

Direct lineavailable toThames Doc

Patient followspreferred route

on pathway

Improved choice at end of life with more patients dying in theirpreferred place of care.Out of hours pathway developed.



Candy JeffriesNational Improvement [email protected]

Dr James BeattieNational Clinical [email protected]

Michael ConnollyNational Clinical [email protected]

Dr David WalkerNational Clinical [email protected]

Elaine KempNational Improvement [email protected]

Carol MarleyNational Improvement [email protected]

Sheelagh [email protected]

Suzanne WhymanProgramme [email protected]

With special thanks to Carolyn Heyes for hercontribution to these projects.

NHS Improvement Heart Failure Team

NHS Improvement3rd Floor | St John’s House | East Street | Leicester | LE1 6NB

Telephone: 0116 222 5184 | Fax: 0116 222 5101

www.improvement.nhs.uk

NHS Improvement

With over ten years practical service improvement experience in cancer, diagnosticsand heart, NHS Improvement aims to achieve sustainable effective pathways andsystems, share improvement resources and learning, increase impact and ensurevalue for money to improve the efficiency and quality of NHS services.

Working with clinical networks and NHS organisations across England, NHSImprovement helps to transform, deliver and build sustainable improvements acrossthe entire pathway of care in cancer, diagnostics, heart, lung and stroke services.

Delivering tomorrow’simprovement agendafor the NHS

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NHSNHS Improvement

©NHS Improvement 2010 | All Rights ReservedPublication Ref: IMP/comms005 - November 2010

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