The rise of chronic conditions like heart disease, diabetes and lung disease are really beginning to impact on our communities and health care services. However it’s the damaging effects on individuals and families that we all meet every day, that really remind me of the urgency of getting our systems right.
Chronic heart failure (CHF) occurs when the heart is unable to deliver oxygen at the rate required by the body. Clinically, sufferers may have symptoms such as breathlessness, ankle swelling, and fatigue and signs such as elevated jugular venous pressure, pulmonary crackles, and displaced apex beat resulting from an abnormality of cardiac structure or function. The diagnosis of CHF can be difficult. Many of the symptoms of CHF can also occur in other important diseases such as lung disease. Many of the tell tale signs of CHF result from sodium and water retention and resolve quickly with diuretic therapy and may be absent in patients receiving such treatment. Demonstration of an underlying cardiac cause is therefore central to the diagnosis of CHF. There are many types of heart disease that can cause heart failure and defining the underlying cardiac problem is also crucial for therapeutic reasons, as the precise pathology determines the specific treatment used (e.g. valve surgery for valvular disease, specific pharmacological therapy for LV systolic dysfunction, etc) (ESC, 2012).
“Chronic Heart failure” is a frightening name for a serious syndrome that can affect a person’s ability to work, engage in day to day activities and can eventually lead to isolation and poor quality of life. It is associated with a higher mortality rate than many cancers. In the last two decades there have been major advances in the medical management of heart failure that can improve the quality and quantity of a patient’s life. Managing heart failure is a team effort and is most effective if the patient understands the condition and engages in self care measures that reduce the impact of the condition. Getting patients actively monitoring for signs of fluid retention, avoiding high salt foods, exercising regularly, taking (often a complex regime of) pills consistently and having structured follow up with specialist and primary health care have all been shown to improve the persons ability to live as normal a life as possible and prevents hospital admissions. However, it is easy to see that there may be many barriers to getting this right.
The 20000 Days project brought together a collaborative group to drive a new way of managing people with CHF admitted to the hospital. Admission with CHF indicates a high risk for readmission or death in the following year, but this risk can be reduced with optimum care. We worked hard to try and understand the issue both from a system and a patient perspective and one of our ideas or Plan-Do-Study-Act (PDSA) cycle to the change improvement minded that we have now implemented is to provide a care “bundle”. Provision of the bundle is ideally triggered by an early, accurate diagnosis, and so the process begins as soon as the patient is identified with suspected CHF. The team visit with the patient in their ward and perform a clinical evaluation that often includes an assessment of the heart function with a hand held echocardiogram (echo). This combination of clinical assessment and technology improves diagnostic accuracy. If the patient symptoms are not due to CHF, other causes can be investigated, and unnecessary heart failure interventions can be avoided. If CHF is diagnosed, a specialist nurse and the cardiologist explain what is happening and discuss and agree a plan. The nurse then comes back later and tries to build a therapeutic relationship, performs a brief but structured assessment and reinforces the information given and often fills in some gaps. The medical team outline the plan of care and as the patient’s symptoms improve the specialist nurse team visit and liaise with the ward team for discharge home. Within 48 hrs a telephone call is made from the nurse who knew the patient and again a structured assessment is obtained and any issues or misunderstandings can be worked through. The medications and treatment plan are discussed and any barriers to adherence are identified and where possible resolved. Within 2 weeks the patient is either reviewed by their GP or when indicated, in the nurse clinic alongside the heart specialist. The patient and the team try to identify self-care issues and work together to problem solve. Medication doses are optimised and the patient is regularly followed until stable and on the best evidenced based medication regime the patient can tolerate. The PHC team is vital to add additional information, strengthen and reinforce the treatment plan, identify any adverse effects and monitor adherence to therapy and we are keen to develop a more integrative pathway. As the patient feels better and responds to therapy it is important to keep patients as healthy as possible and so, we have developed and recently implemented a CHF cardiac rehabilitation programme that includes exercise and self management support. This is also an exciting initiative as it uses the resources already being used by the Better Breathing Team with adaptation of some of their programme to better meet the needs of the patients with CHF. This is a good use of resources and will ensure our service remains sustainable.
But why is this so important? Aren’t things working smoothly without all this change/PDSA stuff? We came across a young man who made me really question our existing system. In 2010, *Peter was a 43 year old Niuean man who was admitted to hospital. He was working and became so short of breath that his boss called an ambulance. In hindsight, he hadn’t been well for many months and had been treated for the ‘flu’ by his GP. He was breathless, felt weak, was aware of his heart racing and had noticed that he couldn’t sleep at night and kept having to get up and go to the window to get some air. His discharge diagnosis was uncontrolled atrial fibrillation (a fast abnormal heart rhythm). He had high blood pressure, he was obese and he had never been “sick” before and didn’t have a clue what to expect. His heart rate was slowed with some medication and in a day or so he felt a lot better. He was discharged with a plan for a follow up appointment to review the need for a cardioversion (a shock to get the heart back on track) and before that he was to have an echocardiogram. The echo occurred 2 months later and showed his heart was severely damaged but the system failed at this point and no follow up occurred, and therefore no echo report went to his GP.
Peter continued to take his warfarin and had regular blood tests which show that he was pretty consistent with his pills, however, because “no news is good news” he stopped taking his heart rate controlling pills. Peter is a nice man and didn’t want to make a fuss. His GP reassured him that he was fine and although he still felt occasionally unwell and tired all the time, he soldiered on……
In February, he arrived back in Emergency Care. His heart was racing. He was full of retained fluid and very short of breath. This time he was identified as needing a cardiologist review. He was seen by the ward cardiology team, together with a specialist nurse. The signs and symptoms of CHF were clear and the diagnosis confirmed with the hand held Echo that showed that Peter’s heart function was extremely poor. On treatment Peter’s symptoms quickly resolved and over the next few days, as he recovered he worked with the whole team including the cultural support team to learn what he had to do to stay well and the team ensured he was started on the appropriate treatment. His long term outcome depends very much on how well his management is addressed over the next few months.
We will never be able to manage all of the patients with heart failure using this intensive approach but we must aim to streamline and improve our response to those who are identified as needing the support most. By working closely with patients like Peter and developing systems that using the skills of the whole team we can give individuals and our community more days free from the frightening symptoms and long term effects of CHF.
*Disclaimer: To ensure confidentiality a fake patient name (Peter) has been used. Some patient details have also been changed
By Andy McLachlan, Cardiology Nurse Practitioner and Dr Mayanna Lund, Cardiologist and co-clinical lead