How to make evidence based practice happen - Identifying the local priorities Dr David Walker NHS Improvement National Clinical Lead for Heart Failure

The role of NHS Improvement Started out as CHD collaborative to assist with implementation of NSF 10 years experience of working with primary/secondary/tertiary care to improve local HF services Publications on individual projects, commissioning, end of life care etc. Recently a more proactive approach, contacting Trusts with long LOS and high readmission rates

What makes a good HF service? Systems for early accurate diagnosis –RAHFC –Availability of BNP to streamline referrals –Access to echocardiography Systems to identify patients in hospital and concentrate them where there is expertise –Access to HF nurse (can “pull” patients to cardiac ward, where there are appropriate protocols in place) –More rapid echocardiography on in-patients

What makes a good HF service? Seamless service –Liaison between in patient HF nurses and community HF nurses to allow prompt discharge –MDT meetings to discuss patients across primary and secondary care – to allow adjusting of medication to prevent unnecessary admissions (regular interaction between medical team, hospital HF nurse(s) and community HF nurse(s) is critical) –Palliative care involvement Above all, a local clinical champion

“NHS : from good to great, preventative, people centred, productive” Early, accurate diagnosis, including the use of diagnostics such as BNP and echo Optimising treatment through medication, rehabilitation and devices if necessary Use of MDTs to provide more seamless care Care co-ordinators to help patients and carers navigate through complex pathways End of Life Care Heart Failure:-

“Early accurate diagnosis” Can be in or out of hospital Rapid Access Heart Failure Clinics –echocardiography on the day –BNP reduces referrals (eg by 30% in Plymouth) –Management plan provided on the day Open access echocardiography BNP in MAU improves speed of diagnosis and access to echo (eg increased echo confirmation of diagnosis from 22-75% in Hemel, with reduced readmissions) Ensure patients are on HF registers

BNP on admission reduces readmissions (W Herts)

“Optimising treatment through medication, rehabilitation and devices if necessary” Systems in place to ensure the optimisation of medication –Hospital HF nurses (in some areas) –Community HF Nurses –GP Practices (incl. practice nurses) –e.g. 16% HF admissions avoidable with correct up-titration of ACE-I and  blockers seen in Rotherham (pharmacist led) Patient education facilitates self-management

Local Enhanced Scheme for GPs - Manchester

Optimising treatment: Rehab in HF Variable evidence base AHA Scientific Statement: Exercise and Heart Failure 2003 –Improved exercise tolerance –Improved endothelial function –Reduced catecholamines –Trials too small to show mortality benefit Efficacy and Safety of Exercise Training in Patients With Chronic Heart Failure: HF-ACTION RCT (2009) –11% reduction in death/hospitalisation –9% reduction in CV death/hospitalisation –15% reduction in CV death/HF hospitalisation

But the bad news is:- –Very variable service across UK –Many rehab services have struggled for staff due to underfunding – and have not seen HF as part of their core service Cardiac Rehab in general is a DH priority –“Unfinished business” from the NSF Optimising treatment: Rehab in HF

Optimising treatment: Devices CRT rates: – improving but still patchy may be a surrogate for a good HF service

Optimising Treatment: Devices ICD implant rates:- Also patchy – but more uniform than for CRT

Concept of integrated care is not a new one… Integrated care requires “methods and organisations to provide the most cost- effective and caring services to those with the greatest health needs and to ensure continuity of care and co-ordination between different services” Integrated Care – Development Issues from an International Perspective: Models and Issues. Healthcare Review, 2(5) March,1998

MDT working in Heart failure Facilitates co-ordination of care Promotes professional collaboration Improves patient satisfaction Reduces resource use and costs? –So far appears cost neutral but with improved quality

Multi-disciplinary Team members Consultant (Heart Failure specialist) GP/GPwSI Community HF Nurses Hospital based HF Nurses Practice Nurses Pharmacists Rehab Team Palliative Care Improvement team

MDT: Integrated care The exact composition of the team in any area doesn’t matter The key is to deliver a seamless service across primary and secondary care (+ tertiary care) A local team leader is essential –usually a consultant Communication is the key –Case management by healthcare professional –Regular case conferences to discuss problems –Carer engagement –Frequent transfer of information across primary and secondary care interface

Hastings: Service Milestones Pre-1999 No formal heart failure service 1999 Part time nurse involvement 2000 Local guidelines on heart failure management 2001 Full time hospital-based nurse appointed Nurse-led heart failure clinic started 2003 Weekly multi-disciplinary heart failure team meeting 2004 Rapid access heart failure clinic introduced Community (BHF) nurses appointed Full integrated service Heart failure ward rounds 2009HF patients concentrated on 2 wards

Hastings v UK HF admissions Independent analysis by David Cunningham, CCAD

Mortality

CRT implantation rising from 2004

No improvement in LOS Hastings 5 th oldest PCT in England – may make it harder to discharge people

Reduced Length of Stay - Essex

LOS / Readmission Rates Trust Code Days 0.00% 2.00% 4.00% 6.00% 8.00% 10.00% 12.00% 14.00% 16.00% Trust LOSNational Avg LOSTrust Readmission RateNational Avg Readmission Rate

MDT and “care co-ordinators” MDT can work well Fewer patients slip through the net Concentrating patients where the expertise exists to look after them allows more streamlined care Community HF nurses make ideal care co-ordinators for heart failure patients –Provide support in patients homes –Telephone advice when required –In regular touch with hospital team providing link between primary and secondary care –Making community services robust 24/7 will be a challenge

Heart Failure Disease Trajectory

End of Life Care in HF Open communication Symptom control Social and spiritual support Advance care planning Preferred place of care Revision of drugs / devices Carer support / bereavement care

Doctors confidence in delivering end of life care Nov 2008

Do you know how you are doing? Composition of service in your area –Are all the appropriate staff in place? –Are there any artificial barriers between primary and secondary care? –Do you have MDT meetings? –Is there any access to rehab? –Is there any interaction with palliative care?

Do you know how you are doing? Is the service well organised? –System for rapid diagnosis of out patients? Community BNP, RAHFC, open access echo? –How are in-patients with HF identified and managed BNP, early IP echo, protocols for IV diuretics, nursed in appropriate area, do patients see a cardiologist/HF specialist? –Discharge planning? (and summary) –Follow up protocols, monitoring etc?

Do you know how you are doing? Do you know your audit data? –What is the local prevalence from GP databases? – is it realistic? –National HF audit –HES data – LOS, readmission rate, mortality? –Do you audit other aspects of your local service?

Why is this work so important? What about the human costs…?