The new Sheffield clinical pathway for heart failure and the GP open access

echo service

Laurence O’Toole

Consultant Cardiologist

Service review heart failure

The performance of this organisation does not meet minimum requirements or the reasonable expectations of patients and the public.

Sheffield PCTs and associated Secondary Care Trusts

Assessment

The PCT and its associated secondary care trust(s) ensures good outcomes for patients by:

• effectively and swiftly diagnosing patients with heart failure, providing them with evidence based treatment and monitoring patients effectively to optimise treatment, detect deterioration and minimise admissions to hospital

• having effective and adequate multidisciplinary services and care processes

• providing patients and their carers with education and support so that they can play an active role in the management of their care

Source Data used for Healthcare Commission Heart Failure Improvement Review

Results of Acute Hospital Portfolio Sept 2005100 Patients (50 per site) diagnosed with Heart Failure

BESPOKE QUESTIONNAIRE(MAY/JUNE 06)7 CATEGORIES

(Categorical & continuous data items)

HF REVIEW RESULTS

Results FEB 07 (provisional)JULY 07 (published)

CENTRAL RETURNS(QOF, diagnostic returns,

hospital episode statistics)

PLAN IMPROVEMENT PHASE

Where Sheffield scored poorly

• No dedicated HF clinic• Long waiting times for echo• Prescribing consistent with NICE guidance• Referral to specialist services• Audit• Overall mortality and admission rates

Prescribing consistent with NICE guidance

% patients with proven LVSD prescribed ACEi/ARBs

• national average 85.2% ± 2.7%

• PCT source data • North 79.9%• West 80.8%• SW 80.9%• SE 77.2%

The diagnosis of heart failure

NICE Guideline Algorithm summarising recommendations for the diagnosis of heart failure

Outcomes from Current Open Access Echo Service

Number of people

scanned

(% total)

Major Echo Finding

(%)

?HF pathway 382 (55%) 37%

Murmur ?cause

pathway

312 (45%) 35%

L O’Toole RHH data

Outcomes from Current Open Access Echo Service

?HF pathway

N=382

REFERRED STH Gen Med/Cardio

in next year

(%)

ADMITTED STH Gen Med/Cardio

in next year

(%)

DIEDin next year

(%)

Major Echo Finding

N=143

57% 28% 10%

No Major Finding

N=239

35% 16% 5%

L O’Toole RHH data

Problems with the Diagnosis of HF in General Practice

Symptoms non-specific

Broad differential diagnosis

Requires access to specialist investigation

Difficult to address with time constraints

Inertia because of complexity of treatment

Patient reluctance to consider investigations

Barriers to accurate diagnosis and effective management of heart failure in primary care BMJ 2003:326;196

Problems with Echocardiography for GPs

Uncertainty about interpretation of technical reports

Perception of long waiting times

Concerns about overloading the service

Inconvenience for patients

Barriers to accurate diagnosis and effective management of heart failure in primary care BMJ 2003:326;196

GP ACCESS TO ECHOCARDIOGRAPHY

Referring GP: (Print Name)

Patients Name: Address: D.O.B: M / F

Tel: NHS Number:

Practice Address: Tel: Fax:

Indication for Referral:

This patient has symptoms or signs suggestive of heart failure plus an abnormal ECG and/or chest x-ray

This patient has a murmur. Is there echo evidence of a significant lesion?

Relevant Medical History: Signed: If there is significant pathology on the Echocardiogram as judged by the reviewing Clinician, a single appointment

in the diagnostic heart failure clinic may be arranged. Please tick if this appointment is not required:

GP ACCESS TO ECHOCARDIOGRAPHY

Referring GP: (Print Name)

Patients Name: Address: D.O.B: M / F

Tel: NHS Number:

Practice Address: Tel: Fax:

Indication for Referral:

This patient has symptoms or signs suggestive of heart failure plus an abnormal ECG and/or chest x-ray

This patient has a murmur. Is there echo evidence of a significant lesion?

Relevant Medical History: Signed: If there is significant pathology on the Echocardiogram as judged by the reviewing Clinician, a single appointment

in the diagnostic heart failure clinic may be arranged. Please tick if this appointment is not required:

GP ACCESS TO ECHOCARDIOGRAPHY

Referring GP: (Print Name)

Patients Name: Address: D.O.B: M / F

Tel: NHS Number:

Practice Address: Tel: Fax:

Indication for Referral:

This patient has symptoms or signs suggestive of heart failure plus an abnormal ECG and/or chest x-ray

This patient has a murmur. Is there echo evidence of a significant lesion?

Relevant Medical History: Signed: If there is significant pathology on the Echocardiogram as judged by the reviewing Clinician, a single appointment

in the diagnostic heart failure clinic may be arranged. Please tick if this appointment is not required:

Single New Patient Appointment in Consultant Cardiology Heart Failure Clinic

Back to GP Care

Reports reviewed and commented on by Consultant Cardiologist

LVSD

No major finding or non-LVSD major finding

Single New Patient Appointment in Consultant Cardiology Heart Failure Clinic

Back to GP Care

LVSD

Nurse-led drug titration clinic

Preferential admission to HF ward areas

‘Interested Physician’ follow up

Hospital admission screening for HF patients by HF nurses

Nurse-led post-discharge HF clinic

Better discharge information

The new Sheffield in-patient pathway for heart failure

GP ACCESS TO ECHOCARDIOGRAPHY

Referring GP: (Print Name)

Patients Name: Address: D.O.B: M / F

Tel: NHS Number:

Practice Address: Tel: Fax:

Indication for Referral:

This patient has symptoms or signs suggestive of heart failure plus an abnormal ECG and/or chest x-ray

This patient has a murmur. Is there echo evidence of a significant lesion?

Relevant Medical History: Signed: If there is significant pathology on the Echocardiogram as judged by the reviewing Clinician, a single appointment

in the diagnostic heart failure clinic may be arranged. Please tick if this appointment is not required:

Single New Patient Appointment in Consultant Cardiology Heart Failure Clinic

Back to GP Care

Reports reviewed and commented on by Consultant Cardiologist

LVSD

No major finding or non-LVSD major finding

The new Sheffield clinical diagnostic pathway for heart failure

GP ACCESS TO ECHOCARDIOGRAPHY

Referring GP: (Print Name)

Patients Name: Address: D.O.B: M / F

Tel: NHS Number:

Practice Address: Tel: Fax:

Indication for Referral:

This patient has symptoms or signs suggestive of heart failure plus an abnormal ECG and/or chest x-ray

This patient has a murmur. Is there echo evidence of a significant lesion?

Relevant Medical History: Signed: If there is significant pathology on the Echocardiogram as judged by the reviewing Clinician, a single appointment

in the diagnostic heart failure clinic may be arranged. Please tick if this appointment is not required:

Please send completed form to either: Echocardiography Department Chesterman Unit Northern General Hospital Herries Road SHEFFIELD S5 7AU Telephone: 0114 226 6128

Echocardiography Department Cardiology Department Royal Hallamshire Hospital Glossop Road SHEFFIELD S10 2JF Telephone: 0114 271 3772

PD 2602 A / June 2008/ V

GP ACCESS TO ECHOCARDIOGRAPHY

Referring GP: (Print Name)

Patients Name: Address: D.O.B: M / F

Tel: NHS Number:

Practice Address: Tel: Fax:

Indication for Referral:

This patient has symptoms or signs suggestive of heart failure plus an abnormal ECG and/or chest x-ray

This patient has a murmur. Is there echo evidence of a significant lesion?

Relevant Medical History: Signed: If there is significant pathology on the Echocardiogram as judged by the reviewing Clinician, a single appointment

in the diagnostic heart failure clinic may be arranged. Please tick if this appointment is not required: