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  1. 1. A sub-group of Lothian Coronary Heart Disease Managed Clinical Network
  2. 2. Normal Heart Failure <ul><li>1 in 10 people aged over 75 years of age have heart failure </li></ul><ul><li>After hospitalisation - 25% mortality, 33% readmitted within 1 year </li></ul><ul><li>Commonest cause in Scotland is coronary heart disease </li></ul>Chronic Heart Failure
  3. 3. Chronic Heart Failure Exhausted and fatigued Breathless Chest pains/palpitations Ankle swelling Unable to do every-day tasks Depressed
  4. 4. Cycles of Heart Failure Care Home GP surgery OP clinic Hospitalisation
  5. 5. Typical Heart Failure Patient 2005 SIGN Guidelines 35, 1999 Diagnosis and treatment of heart failure due to left ventricular systolic dysfunction Treatments Investigations Diuretic FBC, U&E, Glucose ACE inhibitor ECG, Echocardiogram Digoxin Digoxin level in the blood Beta Blocker Statin Warfarin Flu/pneumovax immunisation Spironolactone Cholesterol INR AII antagonist
  6. 6. Caring for a patient with Heart Failure <ul><li>Medical Considerations: </li></ul><ul><li>Tablets & medications </li></ul><ul><li>Regular blood tests </li></ul><ul><li>Other medical conditions </li></ul><ul><li>Immunization </li></ul><ul><li>Close outpatient monitoring for early features of deterioration </li></ul><ul><li>Lifestyle Modifications: </li></ul><ul><li>Weight monitoring/reduction </li></ul><ul><li>Discontinue smoking </li></ul><ul><li>Avoid alcohol </li></ul><ul><li>Exercise </li></ul><ul><li>Salt restriction </li></ul><ul><li>Social & Palliative issues: </li></ul><ul><li>Social needs of patient </li></ul><ul><li>Family/carer support </li></ul><ul><li>Hospice/end of life care </li></ul>
  7. 7. Chronic Heart Failure Primary Care Team GP Practice Nurse Health Visitor Pharmacist Social worker Hospital Team Physician - Generalist Specialist (Cardiology) Specialist (CHF) Cardiology/Rehab Nurse Pharmacist
  8. 8. Primary care Surgery visits Practice nurse Home visits Hospital Admissions OP clinic Primary Care Team GP Practice Nurse Health Visitor Pharmacist Social worker Palliative care team Secondary Care Team Physician Generalist Specialist (Cardiology) Specialist (CHF) Cardiology/Rehab Nurse Pharmacist
  9. 9. Primary care Surgery visits Practice nurse Home visits Hospital Admissions OP clinic GP Practice Nurse Health Visitor Pharmacist Social worker Palliative care team Physician Generalist Specialist (Cardiology) Specialist (CHF) Cardiology/Rehab Nurse Pharmacist Heart Failure Nurse HEART FAILURE TEAM
  10. 10. Lothian Managed Clinical Network (Heart Failure) General practitioner Specialist HF nurses Cardiologist Specialist/EP Geriatrician/care of the elderly elderly Pharmacist Dietitian Palliative Care team Social Services District nurse Rehabilitation Volunteer support workers Patient
  11. 11. Guidelines - evidence based, local needs Web-based decision support program Beta blocker/ACE inhibitor up-titration clinics Direct access echocardiography Brain Natriuretic Peptide & ECG Cardiology OP clinics Data collection & audit Research Palliative Care referral guidelines Education program Specialist Heart Failure nurses Volunteer support program - mentor, non-medical needs Healthcare professional Support for the healthcare professional
  12. 12. http://www.show.scot.nhs.uk/lhfn
  13. 13. Multidisciplinary Team Effect on use of Heart Failure medications April 2005 April 2003
  14. 14. Multidisciplinary care Effects on admissions and time spent in hospital Bed days saved = 582 in 6 months 6 months before and after enrolment in the multidisciplinary CHF service 46% 70% 52% 66% A ll cause admissions Heart Failure admissions Days spent In hospital Days between Hospital admissions
  15. 15. Multidisciplinary care Chest, Heart & Stroke, Scotland <ul><li>10 trained lay-volunteers </li></ul><ul><li>Visiting people with heart failure </li></ul><ul><li>in their own home </li></ul><ul><li>Providing befriending service </li></ul>
  16. 16. Involving Patients and their Families Chest, Heart & Stroke, Scotland Study Group on Heart Failure Awareness and Perception in Europe Heart Failure Patient Forum First meeting on 1 st June 2005 61 patients and carers attended “ ..good to know there are others in the same boat…” “… I felt someone was listening..” Newsletter for patients and carers
  17. 17. Multidisciplinary approach to heart failure management <ul><li>Deliver high quality evidence-based care </li></ul><ul><li>Reduce hospitalisation </li></ul><ul><li>Improve symptoms </li></ul><ul><li>Improve quality of life </li></ul><ul><li>Involve patients and their families </li></ul>
  18. 18. Multidisciplinary Team GP’s Dr Carl Bickler Dr Geoff Dobson Dr Scott Murray Dr Bob Finnie Community Nurses Mary Stewart Nancy Kirkland Pharmacists Fiona Reid Fiona Murphy Managers Lyn MacDonald Anne Ovens Heart Failure Nurses Maureen Smith Janet Reid Sinead McKee Maureen O’Donnell Diane Yellowlees Andrea Ness Susan Brown Patient representatives Linda Garcia Palliative Care Physicians Kirsty Boyd Web programmers Mark Hartswood Database Manager Colin Ferrington Researchers Rebekah Pratt Loraine Francis Care of the Elderly Physicians Patricia Cantley Chest, Heart & Stroke, Scotland Campbell Chalmers Louise Peardon Rae Goode Cardiologists Andrew Flapan Ashok Jacob Martin Denvir Catherine Labinjoh Steve Leslie John Lemaitre

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