New York Heart Association Classification



-382905139065 Primary Care Chronic Heart Failure (Left Ventricular Systolic Dysfunction)How to GuideThe former Public Health Wales Primary Care Quality Team, now incorporated within the Primary and Community Care Development and Innovation Hub, developed a series of quality improvement toolkits to assist practices in collating and reviewing information. From information received, practices still find these toolkits useful, therefore they will remain on this webpage for your ease of reference. Please note, however, that the date of publication is clearly stated in the toolkit and that the evidence within may have changed since publicationThis guide has been produced to enable GP Practices and their teams to successfully implement a series of care bundles in a timely manner and apply the Model for Improvement when monitoring patients with suspected /confirmed Heart Failure. There is a summarised version of this document which can be accessed atPCQIS site 2012 AcknowledgementsThis guide has been produced by Primary Care Quality & Information Service (PCQIS) with input from Dr Paul Myres, Debbie Davies, Dr Graham Thomas, Dr Richard Lawrance, Louise Howard Baker, and Breeda Worthington (NLIAH) and the All Wales Cardiac Network Groups.We would like to thank Health Boards and GP Practices in Wales and their teams for their endeavours in implementing these interventions and also feeding back lessons and experiences gained.PCQIS and 1000 Lives Plus have successfully engaged with a number of experts in Primary and Secondary care to produce this guide for Chronic Heart Failure. It has been developed by specialist practitioners in Wales and the content based on evidence and recommendations from NICE1, National Heart Failure Audit 2012 2, European Society of Cardiology (ESC) guidelines for the diagnosis and treatment of acute and chronic heart failure 20123, Cardiac Disease NSF for Wales4, PCQIS chronic heart failure toolkit5, Welsh Medicines Resource Centre 6, European Society of Cardiology (ESC) 2008 Acute and Chronic Heart Failure Clinical Practice Guidelines 7, Prodigy (formerly CKS) Chronic Heart Failure guidelines 2010.8 We wish to thank and acknowledge the Institute for Healthcare Improvement (IHI) and the Health Foundation for their support and contribution to 1000 Lives PlusDate of publication and Proposed Review Date This guide was published in December 2012 and will be reviewed in 2014. The latest version will be available online on the programme’s website: 1000livesplus.wales.nhs.ukPurpose of the GuideThe aim of this guide is to assist practices to review the quality of the service that they provide to patients with suspected /confirmed Chronic Heart Failure.It has been produced to enable GP Practices and their teams to successfully implement a series of care bundles in a timely manner, and to improve the safety and quality of care that their patients receive.This ‘How to Guide’ must be read in conjunction with the following:Leading the Way to Safety and Quality Improvement to Improve The Quality Improvement GuideFurther information is also available to support you in your improvement work:PCQIS site siteThe new GP Appraisal & CPD website can be found here; Lives Plus 14 Cathedral Road, Cardiff CF11 9LJ | Tel: (029) 2022 7744Email: 1000livesplus@wales.nhs.uk | Web: 1000livesplus.wales.nhs.ukTwitter: 1000livesplusForeword All general medical practices will have patients with heart failure. Research has shown what treatments improve quality of life and prolong life. Guidelines have been published to help us deliver those treatments. However, we know that not all eligible patients are receiving those treatments. This guide, and its associated collaborative programme, aims to put that right by encouraging and supporting primary medical care teams to examine the care they provide, reflect on their services and try different approaches as necessary to improve. The 1000 lives plus approach requires practices to design their processes to meet the needs of their patients in ways appropriate to their circumstances by considering their own data and comparing it with what they would wish it to be. It encourages practices to compare themselves with others and learn from what others have done. Similarly it asks participating practices to share their learning with others. This is the first “How to Guide” specifically aimed at general medical practice. It is concerned with an area of disease where we know collectively we can do better. It relies on us to work constructively with our secondary care colleagues. It puts responsibility on all of us in the general medical practice team to improve.Paul MyresPrimary Medical Care Lead1000 lives plusChairRoyal College of GPs WalesMaking Patient Safety a priority The 1000 Lives Campaign has shown that by working as a collaboration it encompasses not only health services within secondary care organisations but also community based alliances from health clinics and associated general practices who together support mutual aims: the avoidance of unnecessary harm, improvement to services that are delivered and an evidence-informed approach with patient safety as a priority.The enthusiasm, energy and commitment of teams to improve patient safety by following a systematic, evidence-based approach has resulted in many examples of demonstrable safety improvement.However, as we move forward with 1000 Lives Plus, we know that harm and error continue to be a fact of life and that this applies to health systems across the world. We know that much of this harm is avoidable and that we can make changes that reduce the risk of harm occurring. Safety problems can’t be solved by using the same kind of thinking that created them in the first place. In General Practice the field of patient safety has tended to focus on adverse events and on the development of specific solutions aimed at preventing these events. We know that much of the harm is avoidable and that changes in practice and procedures can reduce the risk of harm occurring. Developing a positive safety culture depends on communication between all members of the health care organisation. The health care organisation needs to:Acknowledge the scope of the problem and make a clear commitment to change.Recognise that most harm is caused by bad systems and not bad people.Acknowledge that improving patient safety and outcomes requires everyone on the health care team to work in partnership with one another, patients and families.The national vision for NHS Wales is to create a world-class service by 2015; one which minimises avoidable death, pain, delays, helplessness and waste. The guide is grounded in practical experience and builds on learning from organisations across Wales. The National Patient Safety Agency Seven Steps to patient safety in general practice guide describes the key steps for a general practice to take to avoid harming the patients they care for. PageIntroduction 6Driver Diagram 9Getting Started 10Drivers and Interventions 11How do we introduce changes to processes?16How do we measure for Improvement?19References24AppendicesSetting up your team 25The Model for Improvement27How to test change28Process Measures with descriptors 29READ codes 32 Helpful Resources 38 Glossary 46IntroductionAim: To Reduce Morbidity for patients with Chronic Heart Failure (CHF) (Left Ventricular Systolic Dysfunction) (LVSD)Heart failure is increasing in prevalence as a chronic condition and it presents significant challenges to individuals, their families and the healthcare system.Currently 900,000 people in the UK have heart failure. The incidence and prevalence of heart failure rises steeply with age, the average age of first diagnosis is 76 years. Heart failure has a poor prognosis, almost 40% of patients diagnosed die within a year.1,2 Prevalence of recorded heart failure mostly falls short of predicted levels which could indicate that there is a largely unseen demand for investigations, clinical assessment and care. There are several types of heart failure2. The strongest evidence base at present is for Left Ventricular Dysfunction (LVSD).Whilst substantial progress has been made over the last few years, there is considerable national variation8:Variation between different groups of patients.Variation in the confirmation of a diagnosis.Variation in access to evidence-based treatment and heart failure specialist staff.The impact of delivering evidence-based careOne of the main objectives of managing patients with CHF is to introduce appropriate drug therapy, including ACE inhibitors and beta-blockers, ideally titrating doses up to the optimal target doses used in the large randomised controlled trials. There is good evidence that this goal can be achieved in the majority of patients if a determined and concerted effort is made in hospital, at outpatient clinics and in the community.1Over 50 clinical trials have shown that, in patients with reduced left ventricular systolic function, ACE inhibitors, angiotensin receptor blockers (ARBs), and beta-blockers reduce symptoms, readmission rates, and mortality. Studies report that the use of ACE inhibitors or ARBs at optimal doses reduces the risk of mortality by 15-25% and anticoagulation for people with heart failure who have atrial fibrillation reduces risk of stroke by 60-70%. When a variety of different pharmacological options are available, positive benefits are achievable if the drugs are provided appropriately and patients are supported to be concordant with their treatment.1,2The NSF and associated guidelines, underpinned by audit and evaluation, emphasise the need for improved access to diagnostic services (including echocardiography and B-type natriuretic peptide (BNP) testing), and robust clinical management involving non pharmacological and pharmacological treatment, including resynchronisation device therapy, assist devices and transplantation. Once the diagnosis of CHF is confirmed, patients can be started (often sequentially) on appropriate medication and a care pathway with the aim of relieving symptoms, improving health-related quality of life, and reducing morbidity and mortality.1,9The role of Primary Care in delivering improvement (QOF) 2011/12There is good evidence that appropriate diagnosis, treatment and management can improve quality of life and help reduce admissions and readmissions, morbidity and mortality2The General Medical Services Quality and Outcomes Framework (QOF) manages chronic diseases in primary care and incorporated three measures on the diagnosis and management of heart failure. However, there is still wide variation in the number of patients on GP disease registers with suspected heart failure. Local prevalence of recorded heart failure mostly falls short of predicted levels1, which could indicate that there is a largely unseen demand for investigations, clinical assessment and care. The role for Primary Care service is to implement reliable interventions described in this guide and then to focus intensively on managing CHF patients safely.Data Quality System (DQS) in Wales and Audit+In November 2007, the Welsh Government’s Primary Care Informatics Programme (now part of NHS Wales Informatics (NWIS) launched the Data Quality System. This was a natural progression from previous initiatives with the aim of providing an efficient, automated and consistent software tool, primarily to support General Medical practices and as a by-product support the bigger picture within Wales.The DQS comprises of a General Practice based tool, ‘Audit+’ and a secure central NHS Wales-based web repository ‘Audit Web’ which receives scheduled automated aggregate data submissions from Audit+.Participation in the DQS within Wales is voluntary; Audit+ is provided free to all General Practices in Wales irrespective of their clinical information system and is now deployed in 97% of General Practices. To ensure continued acceptance from practices, reflected in continued high level of participation, the development and implementation of all modules is discussed with GPC (Wales) representatives to guarantee ongoing professional approval. NWIS works closely with Public Health Wales and other key NHS organisations to produce modules within Audit+ including amongst others:INR MonitoringMinor SurgeryLearning DisabilitiesNear Patient TestingQOF age/sex standardised prevalenceFlu vaccinationsPneumococcal vaccinationsCommunicable diseasesCHD National Service FrameworkDiabetes National Service Framework / Directed Enhanced ServiceAs is the case with any software product the results produced are only as good as the source data supplied. Audit+ therefore contains specific searches within other modules to encourage General Practices to improve the data quality within their clinical system that supports their day-to-day activities. Audit+ modules to support cardiovascular risk will also contain such searches to ensure that the data required to undertake risk calculations is as complete as possible.Registration processThe Audit+ product collects data from all practices who have signed up to its use. The Practice or service provider will be undertaking testing and measurement of ideas using the improvement methodology as part of a collaborative, made up of themselves and other practices or service providers. The precise size and form of the collaborative will be determined over the coming months. It will be a voluntary subscription to undertake the interventions described in this improvement guide. In order to filter data from the Audit + tool, to feed back to practices who have subscribed to the collaborative(s), the 1000 Lives Plus programme will need to identify who has subscribed to which collaborative (defined by its improvement focus e.g. Chronic Heart Failure). In order to do this, the practice, once signed up to a collaborative, will need to register and accepted that they have agreed to take part in the particular collaborative(s). The registration will take place using the existing “Public Health Wales PCQIS Quality Improvement Tools”, which will be familiar to many GP practices because it hosts the all Wales clinical governance self assessment tool. There will be 1000 Lives Plus collaborative registration form available at this site. Practice Registration Form Purpose of the Registration FormThe Registration Form will allow practices and other providers to register their subscription to one or more of a number of quality improvement collaboratives covering a range of clinical practice issues, starting with a choice ofChronic Heart Failure (Left Ventricular Systolic Dysfunction)Atrial FibrillationAnti coagulation therapy using warfarinPractices or other service providers will be able to sign up to one or more of thesecollaborative. The registration tool will allow practices to add data that the Audit + tool is not collecting but is important to the subject matter. It will also allow practices to annotate issues or constraints associated with their audit/measurement ranging from internal practice issues, practice development issues identified or lack of services that may prevent the implementation of evidence based quality improvements. It will also provide summary data collection forms for those not signed up to the Audit+ tool.The issues identified from data collected from the registration form?will allow any analysis to be qualified with constraints and caveats to promote?a more effective discussion of quality improvement within collaborative learning sessions.InterventionsAimDriverCare Bundle 1Refer all patients with previous MI for echocardiography if not already done post MI * Patients presenting with persistent breathlessness should be clinically assessed for the possibility of Heart FailurePerform an ECG on all patients with suspected Heart FailureIf ECG abnormal refer for echocardiographIf ECG normal measure Plasma B-Type Natriuretic Peptide (BNP). If BNP raised refer for EchocardiogramIf AF present use CHADS2 score to assess need for anticoagulation Diagnosis & InvestigationCare Bundle 2Treat all who can tolerate therapy and for whom there are no contraindications, initially with an ACE/ARBs Inhibitor at low dose, titrating upwards to maximum1Use licensed beta-blocker therapy for patients with Left Ventricular Systolic Dysfunction (LVSD), where there are no contra-indications and optimisation of dose to maximum tolerated (resting heart rate <65 b.p.m Provide aldosterone antagonists to all patients who are NHYA 2-4 after optomisation of ACE-I/ARBs and BB 3Reduce Morbidity for patients WithCHF (LVSD)Effective drug therapyCare Bundle 3Patients should be given verbal and written information about their condition (See appendix...main guide)Patients should have a clear discharge plan from secondary care and an agreed self management planEffective clinician/patient PartnershipReducing the Risk of infections Care Bundle 4Offer Influenza and Pneumococcal Immunisation* If unsure, check through hospital letters for mention of a recent echo report prior to referral for the patients who are symptomatic post MI. Getting StartedThe practice needs to think about their current local systems and processes and use this guide as a starting point to think creatively about ideas to test. Engage the rest of the practice team and ensure effective communication systems are in placeAssign roles and responsibilities around CHFReflect and review, as a team, on what you are doing (integral to PDSA method).Involve the practice nurse (eg. assessing patients for risk factors, using information management systems to identify and recall patients, setting up health displays to encourage patient education so that patients ask about managing their condition)Involve administration staff (eg. using information management systems to identify and recall patients)Identify and action opportunities to clean data (eg. reception staff check patient information)Setting Up your team:Identify a clinical lead (Lead GP)Identify a managerial lead (GP, Practice Manager, Practice Nurse)Clarify who is responsible for day to day leadership (Practice Manager)See Appendix A for further informationDo you and your team understand how to apply the Model for Improvement?The Model for Improvement is a fundamental building block for change and you need to understand how to use it to test, implement and spread the interventions in this guide. See page 16 for further details on the Model for Improvement and the ‘How to Improve’ Guide. What should we be doing?PCQIS has used the evidence gathered to produce the driver diagram to summarise desired outcomes and how they can be achieved. The driver diagram will help the practice translate a high level improvement goal into a logical set of underpinning, evidence-based goals (‘drivers’). It captures an entire change programme in a single diagram and also provides a measurement framework for monitoring progress.Care BundlesThe driver diagram details a series of 4 care bundles. Care Bundles are elements of evidence based research which can be delivered to a selected group of patients. It provides a systematic approach to care delivery to ensure a uniformity of implementation. When performed collectively, reliably and continuously, the bundles have been proven to improve patient outcomes. (See page 9).How are you going to measure process reliability?In order to improve outcomes for your patients you need to demonstrate you are using these interventions reliably. This means that all the interventions within each bundle MUST be complied with to achieve successful completion of that bundle. You need to do this by using the process measures in this guide.See the ‘How to Improve’ Tools for Improvement guide and Appendix C for a summary of all process measures.Drivers and Interventions - Supporting EvidenceThis section details the evidence that underpins the driver diagram that has shown to be effective in treating Chronic Heart Failure.As a practice (or at least one GP and one other staff member), choose an area where you feel you need improvement in order that your practice is in line with the evidence. Choose an area where there is likely to be a significant gap between what you currently do and what the evidence based guidelines suggest you do or where your level of delivery is below what you would wish.Where the recommendations diverge from usual practice explore these recommendations in more detail. Each recommendation is discussed in detail in the full Heart Failure Nice guideline: or NICE Pathways:HYPERLINK "" helpful resources (appendix E number 1)Remember The Chronic Heart Failure Bundle is a series of interventions related to heart failure care that, when implemented together, will achieve significantly better outcomes than when implemented individually. Bundle 1- Diagnosis & Investigation all patients with previous MI for echocardiography if not already done post MI.Note: First consider those patients who have a past diagnosis of a MI and who present with symptoms, even if mild15 RationaleHeart Failure is defined, clinically, as a syndrome in which patients have typical symptoms (e.g. breathlessness, ankle swelling, and fatigue) and signs (e.g. elevated jugular venous pressure, pulmonary crackles, and displaced apex beat) resulting from an abnormality of cardiac structure or function.7The typical presentation of heart failure in primary care is insidious, with progressive breathlessness on exertion, ankle swelling, orthopnoea or paroxysmal nocturnal dyspnoea. Not all patients will have all these symptoms, and in many patients there may be other causes. 15Refer directly to echocardiography if a patient has a history of myocardial infarction or basal crepitations or is a male with ankle oedema. 15i) Perform an ECG on all patients with suspected Heart FailureRecommendation Patients suspected of heart failure should be identified and an ECG performed and referred in a systematic way.1Rationale:NICE recommend either a natriuretic peptide or an ECG being performed as a triage test prior to echocardiography. NICE guidance is of the opinion that performing an ECG should be part of the general assessment of a patient in whom heart disease is suspected to determine the patient’s rhythm, heart rate control, the presence of conduction abnormalities, the duration of the QRS complex (to determine the appropriateness of cardiac re-synchronisation therapy), and to monitor heart failure patients having their beta-blocking doses up-titrated. While it is no longer recommended as part of the diagnostic algorithm for heart failure (being replaced by natriuretic peptide), NICE wished to emphasise that the electrocardiogram remains an essential test to be performed in all patients with heart failure.ii) Echocardiography at diagnosis.Recommendation Patients at risk of heart failure and those suspected of heart failure should be identified and assessed and referred for echocardiography in a systematic way1Rationale:All patients with acute or chronic heart failure require confirmation of the underlying structural or functional abnormality. Echocardiography allows assessment of systolic and diastolic ventricular function including left ventricular ejection fraction (LVEF). It also assesses chamber size, wall thickness, regional wall motion abnormalities and valvular function. As part of the referral process for the Specialist Heart Failure Nursing Service an echocardiogram needs to have been undertaken.iii) B-type Natriuretic Peptide (BNP) monitoringRecommendation If a GP suspects heart failure, then the key blood test is B-type natriuretic peptide (BNP). If the BNP is normal then heart failure is unlikely and other diagnoses should be considered. If it is raised, or if there is a past history of myocardial infarction, the patient requires further assessment, which must include echocardiography and a specialist assessment. There should be a clear practice pathway or practice protocol in place to ensure patients are assessed and referred appropriately.1Rationale:Performing BNP as a first-line test for heart failure:Performing a BNP test or an ECG as an initial test for patients with suspected heart failure can be recommended as these tests have high sensitivity for detecting heart failure 1, 2. Heart Failure is unlikely if these test results are considered to be normal. Patients who are found to have a normal BNP and ECG can proceed on to other disease care pathways so that their diagnoses can be reached without further unnecessary delay.Patients with suspected heart failure and no previous MI – measure serum natriuretic peptides:If high levels, refer within 2 weeks for Doppler 2D echocardiography and specialist assessment.If mild to moderately raised levels, refer within 6 weeks.NICE guidance 2010 recommends the following:1. BNP>400 pg/ml (>116 pmol/l) or NT-proBNP>2000 pg/ml (>236 pmol/l): Need an echocardiogram and specialist clinical assessment no longer than 2 weeks from the time of presentation2. BNP 100-400 pg/ml (29-116 pmol/l) or NT-proBNP 400-2000 pg/ml (47-236 pmol/l): Need an echocardiogram and clinical assessment by the Specialist within 6 weeks from the time of presentation.3. BNP <100 pg/ml (<29 pmol/l) or NT-proBNP <400 pg/ml (<47 pmol/l), in the absence of heart failure therapy: Heart Failure is an unlikely cause for the presentation.IV) Atrial fibrillation RecommendationPatients with persistent/permanent Atrial Fibrillation (AF) should be started on anticoagulantsRationale:Patients with AF are at risk of forming small thrombi within the heart chambers that can embolise and cause stroke or TIA. CHADS2-VASc scores will assess likely risk in order to determine the need for anticoagulation.10 The CHADS2 VASC scoring system has superceded the old CHADS2 scoring system and is the preferred tool for stroke/ TIA risk assessment in patients with AF See helpful resources (appendix E number 2).Bundle 2 - Effective drug therapy Patients with heart failure due to left ventricular systolic dysfunction must be routinely considered for ACE-inhibitor treatment and beta blockers,.Rationale:The morbidity and mortality rates of heart failure have progressively fallen through the accumulative effects of several classes of agents including angiotensin converting enzyme inhibitors, beta-blockers, aldosterone antagonists, combined arterial and venous dilators (combined hydralazine and nitrates) and angiotensin receptor blockers. These advances have been achieved in the treatment of heart failure associated with reduced left ventricular ejection fraction or HF with LVSD, which comprises almost 50% of the heart failure patient population. Systematic reviews of randomised control trials have established that ACE inhibitors improve symptoms, reduce the risk of hospitalisation for heart failure and increase life expectancy, compared with placebo. The beneficial effect is more evident in those patients with severe symptoms. In patients truly intolerant of ACE-inhibitors, ARBs can be used as an alternative but it is likely they are not as effective in reducing hard end-points.Beta-blockers can significantly improve mortality and reduce hospitalisation in patients with all grades of heart failure. Beta-blocker therapy is recommended in all patients with CHF in addition to standard therapies of ACE inhibitors and diuretics, regardless of whether symptoms persist or not. Several systematic reviews provide consistent evidence of the benefits of beta-blockers compared with placebo.NICE1 and SIGN 11guidelines therefore recommend that licensed beta-blockers should be used when initiating therapy in heart failure. Only Bisoprolol, Carvedilol and Nebivolol (in patients aged over 70 years) currently have heart failure as a licensed indication in the UK. Current NICE guidance1 states that patients who are already taking beta-blocker therapy (e.g. atenolol) when they develop heart failure can either continue with their current beta-blocker or change to a licensed alternative. Switching to a licensed beta-blocker may be an improved option, as evidence suggests the benefits of beta-blockers may not be a class effect.Very often it is the dose of beta-blocker that is not tolerated rather than the drug per se. It is better to give a low dose of beta-blocker than none at all, while individualisation of dosage is critical to allow all eligible patients, including older people, to benefit from the treatment. However, more cardioselective beta-blockers, in particular nebivolol (and possibly bisoprolol) are often tolerated when others have not been and should be considered in this circumstance.It is important to start at a low dose, up-titrate the beta-blocker doses gradually to the target or highest tolerated dose and defer therapy in patients who are not stabilised and/or have more than minimal evidence of fluid overload or volume depletion. Therapy should be provided to all eligible patients, provided that the patient is stable, does not meet exclusion criteria and will receive follow-up. RecommendationIn addition to an ACE inhibitor and a beta-blocker consider adding an aldosterone antagonist licensed for heart failure (especially if the patient still has symptomatic heart failure [NYHA class II–IV] or has had a MI within the past month) 1Rationale:The aldosterone antagonist spironolactone can be added to an ACE inhibitor and a beta-blocker in patients who continue to remain symptomatic; low doses of spironolactone reduce symptoms and mortality in these patients. If spironolactone cannot be used, eplerenone may be considered for the management of heart failure especially after an acute myocardial infarction with evidence of left ventricular systolic dysfunction. Close monitoring of serum creatinine, eGFR, and potassium is necessary, particularly following any change in treatment or any change in the patient’s clinical condition. 12Bundle 3 - Effective clinician/patient Partnership Recommendation There should be clear communication between clinicians and patients as to further management. Ideally every patient should have a written self management plan and be considered for referral to a specialist heart failure (nurse-led) team.Rationale:Patients who understand their condition better and what the treatment is for cope better. Patients are frustrated when they feel there is lack of communication between secondary and primary care. Poor planning is more likely to lead to readmission. Encourage patients to recognise deterioration of their symptom control, give them confidence in obtaining advice and assistance from Specialist CHF Nurses. (See appendix E helpful resources).Discharge planning to take account of the following: patient and carer wishes and the level of care and support that can be provided in the community – this information should be accessible to the primary care team; specific behavioural/lifestyle issues that can affect the risk of development and progression of CHF; information of who to contact for advice and support immediately following discharge and patient information leaflets or booklets.Bundle 4 – Reducing the Risk of infections Recommendation All patients without contraindication should be offered immunisation for Influenza and Pneumococcal infection.Rationale:Influenza and pneumococcal immunisation are included as components of the care bundle based on recommendations from the Advisory Committee on Immunisation Practices (ACIP). ACIP recommends special priority for immunisation of individuals with pulmonary or cardiac disease13and influenza immunisation reduces the risk of hospitalisation for patients with heart failure.Pneumococcal vaccine is especially recommended for persons with heart failure. It is most effective in preventing invasive disease, for which heart failure patients are at higher risk. Vaccination is a primary care intervention, as responsibility for providing immunisation falls under the General Medical Services Contract. Practitioners from any care environment should inform and encourage CHF patients to ensure they receive this protection.How do we introduce changes to processes?Making improvements to products, systems or services requires change. Although change can seem threatening or overwhelming for busy people, it can be successfully managed if well planned. The Model for ImprovementThe Model for Improvement provides a framework for developing, testing and implementing changes. It helps to break down the change effort into small, manageable chunks which are then tested to ensure that things are improving and that no effort is wasted. It is always worth remembering that while every improvement is certainly a change; every change is not an improvement.The Model for Improvement consists of two equal parts; the first part, the ‘thinking part’, consists of three fundamental questions to guide improvement work:? What are we trying to accomplish?? How will we know that a change is an improvement?? What changes can we make that will result in an improvement?The second part, the ‘doing part’, is made up of rapid, small ‘plan, do, study, act’ (PDSA) cycles to test and implement change in real work settings. The PDSA cycle provides a framework for testing ideas and assessing the results to determine if the change is an improvement and shares many attributes with the classic audit approach.PDSA is a model for testing ideas that you think may create improvement in a situation. It can be used to test ideas for improvement quickly and easily based on existing knowledge, research, feedback, theory, review, audit, or by adapting practical ideas that have been proven to work elsewhere. The answer (or answers) to the third fundamental question: ‘What changes can we make that will result in an improvement?’ will form the ‘change ideas’ (or objectives) to lead each PDSA cycle. It is important to remember that a project will usually be broken down into a number of PDSA cycles.There are many things to consider and techniques to employ, which are captured in the ‘Appendix B– The Model for Improvement Driver Diagram.See Appendix C for further guidance on PDSA cycles to assist you to make changes in your practice that can be used to support the implementation of the Heart Failure Driver Diagram. Successful improvement initiatives don’t just happen – they need careful planning and executionIn any improvement initiative you need to succeed in three areas. You need to generate the Will to pursue the changes, despite difficulties and competing demands on time and resources. You need the good Ideas that will transform your service. Finally you need to Execute those ideas effectively to get the change required.WillThe interventions you need to build Will are explained in the ‘Leading the Way to Safety and Quality Improvement’ and ‘How to Improve’ guides. They concentrate on raising the commitment levels for change and then providing the project structure to underpin improvement approaches. Spreading changes to achieve transformative change across the whole health system requires strong leadership.We need to create an environment where there is an unstoppable will for improvement and a commitment to challenge and support teams to remove any obstacles to progress.IdeasThe interventions in this guide describe ideas which evidence shows to be effective for achieving changes that result in improvements. It gives examples from organisations that have achieved them and also advice based on their experience. Methods and techniques for generating new ideas or innovative ways to implement the evidence can be found in the ‘How to Improve’ guide and other improvement literature.ExecutionHowever, to bring these ideas into routine practice in your organisation, it is essential that you test the interventions and ensure that you have achieved a reliable change in your processes before attempting to spread the change more widely.How will we know that a change is an improvement? In order to answer this, practices will need a defined process measure (such as compliance with all elements of a care bundle) which is evidently linked to an outcome measure (such as an increase in the numbers of referrals for echocardiograph). Both process and outcome data which are linked are essential to evaluate the effectiveness of change. The data the practice collects in real time can be used to tell the improvement story and build the case and/or argument to change practice in order to improve outcomes.3To improve outcomes for patients the practice needs to demonstrate that they are using the interventions in the driver diagram reliably. This means that all the elements of the interventions are performed correctly on 95% or more of the occasions when they are appropriate (A lower limit may be acceptable in small population sizes or where there are variable that are beyond control).NoteThere should be a measure of compliance with each main indicator.How do we measure for Improvement?Start collecting the data and using it for local decision making using the Seven Steps to Measurement:1 Decide aim2 Choose measures3 Define measures6 Review measures5 Analyse & present7 Repeat steps 4-64 Collect dataIn this Chronic Heart Failure Guide, steps 1-3 have been established:Step 1 - What are we trying to accomplish?An aim needs to be Specific, Measurable, Achievable, Realistic andTime-bound (SMART). Everyone involved in the change needs to understand what this is and be able to communicate it to others: To reduce morbidity for patients with CHF (LVSD)Step 2 - How will we know that change is an improvement?It is essential to identify what data is needed to answer this question and how to interpret what the data is telling us. Step 3 – Define measuresThe process measures have been defined and are listed in appendix C (Page 28).Practices now need to implement steps 4-7-(CAR) collect, analyse, and review data.The key is to go round the Collect-Analyse-Review cycle frequently: Collect your dataAnalyse - turn it into something useful like a run chartReview - meet to decide what your data is telling you and then take action. Successful improvement projects all have clear aims, robust measurement and well-tested ideas. Use the ‘How to Improve’ guide to ensure your projects have all three.Step 4 – Collect your dataThe practice will need to know their baseline before they can track the progress of their goal against it. Continuous data collection will be collected mainly via the Audit+ software within your practice. Data will be analysed and fed back to practices and local networks by the Primary Care Quality Information Service (PCQIS).The first collection of your data will provide a ‘baseline’ of current performance. Thereafter running and reviewing the data collection at an agreed frequency will give you a more regular idea of how well you are doing. Practices may wish to allocate their own standards to the recommended process measures following a review of their baseline data from PCQISBy starting measurement and plotting points the practice will be able to create their baseline. To create a baseline or identify a trend the practice can start using a run chart. A run chart is a simple line graph which is used to track the performance of one (or more) steps in the process targeted for improvement across a defined period of time. “Practices may be able to develop their own run charts from Audit + data at the practice which will be available more frequently than the PCQIS reporting”Run charts are the visual expression of the process measure developed. Plotting the dots’ is very effective because it will help the practice spot trends and patterns displayed about 25 data points are ideal. However, 20 data points will provide a robust representation. One way to get more points is to measure more frequently. Often the data needed to measure is not being collected. If so, the practice should start collecting data straight away. But the practice does not have to wait to start making small changes. They will not affect the overall situation so you can be doing those while creating the practice baseline.Run charts can:Help improvement teams formulate aims by depicting how well, or poorly, a process is performing. Help in determining when changes are truly improvements by displaying a pattern of data that the practice can observe as they make changes.Give direction as work on improvement and information about the value of particular changes.Further information on the construction, interpretation displaying time series data and analyses of run charts can be found at How to Improve’ Guide. collect data?How can the practice compare, quantify or record changes if the practice have not captured any data.Without measurable data the practice is at the mercy of anecdote. If the practice make an assumption based on anecdote rather than data, it will nearly always be wrong because people remember the unusual, not the mundane.How will the practice know that any changes they have made will result in an improvement? Note: Continuous data collection will be collected mainly via the Audit+ software. Data will be analysed and fed back to practices and local networks.Step 5 - Analyse Improvement takes place over time. Therefore, determining if improvement has really happened and if it is lasting requires observing patterns over time. Step 6 – Review your data to decide what it is telling youIt is vital that the practice set time aside to look at what the measures are telling them. The frequency with which the practice collect, analyse and review their data sets the pace for change for improvement.How will the practice know that a change is an improvement?1. By understanding the variation that lives within the data.2. By making good decisions on improvement choices (i.e. don’t overreact to a special cause and don’t think that random movement of your data up and down is a signal of improvement).One of the key strategies in improvement is to control variation- Further reading on Variation, as a measure of quality can be accessed at How to Improve’Guide 7 – Repeat steps 4 to 6This is an iterative process. The purpose of measurement is to lead the practice to making the right decisions about their improvement project. Even if the practice are consistently meeting their goals they should still look to see if there are further improvements that could be made. If the practice aimed for 0% or 100% and are meeting it reliably the practice should still continue to measure so that any deviations are picked up and acted upon quickly. In these cases the practice may decide to measure less frequently, however be aware that the process of measuring does have a positive effect in keeping awareness high and demonstrating that the goals measured is important to the practice.Remember:Plot data over time - Tracking a few key measures over time is the single most powerful tool a team can use.Seek usefulness, not perfection. Remember, measurement is not the goal; improvement is the goal. In order to move forward to the next step, a team needs just enough data to know whether changes are leading to improvement.Use sampling. Sampling is a simple, efficient way to help a team understand how a system is performing.Integrate measurement into the daily routine. Useful data are often easy to obtain without relying on information systems.Use qualitative and quantitative data. In addition to collecting quantitative data, be sure to collect qualitative data, which often are easier to access and highly informative.Understand the variation that lives within your data. Don’t overreact to a special cause and don’t think that random movement of your data up and down is a signal of improvementHow to successfully introduce change and Build the will to make improvementsAfter testing a change on a small scale, learning from each test, and refining the change through several PDSA cycles, the change is ready for implementation on a broader scale-for example, for an entire practice population or on an entire unit. Achieving change will require consistently applying a range of improvement initiatives into the daily work of the practice.Strong leadership within the practice is critical to building the will to changeSetting clear improvement aims and monitoring progress against them is a primary task for the practiceCommitment to develop practice staff at all levels in the skills needed to lead and deliver improvement initiatives.Implementation is a permanent change to the way work is done and, as such, involves building the change into the practice. It may affect documentation, written policies, hiring, training, and aspects of the practice infrastructure that are not heavily engaged in the testing phase. Spreading ChangesSpread is the process of taking a successful implementation process from a pilot unit or pilot population and replicating that change or package of changes in other parts of practice organization.?During implementation, teams learn valuable lessons necessary for successful spread, including key infrastructure issues, optimal sequencing of tasks, and working with people to help them adopt and adapt a change. ?Locality based Learning sessionsPockets of excellence exist in our Primary Care health care systems, but knowledge of these better ideas and practices often remains isolated and unknown to others.A schedule of local learning events (Primary Care collaborative) will be delivered within each Health Board locality to share data/learning issues emanating from practices. This communication method will provide an opportunity for adopters to ask questions, explore solutions among colleagues, share learning, and deepen their understanding of the changes the practices are making.ReferencesNational Clinical Guidelines Centre (2010) Chronic Heart Failure CG108: The management of chronic heart failure in adults in primary and secondary care (revised). Heart Failure Audit 2012 Society of Cardiology guidelines for the diagnosis and treatment of acute and chronic heart failure 2012 Cardiac Disease National Service Framework for WalesJune 2009: Standard 4 managing the care of patients with chronic heart failure Heart Failure toolkit PCQIS Medicines Resource Centre; Treatment of chronic heart failure (November 2008) Society of Cardiology (ESC) 2008 Acute and chronic Heart Failure Clinical Practice Guidelines guidelines/GuidelinesDocuments/guidelines-HF-FT.pdfCKS chronic heart failure 2010 Commission (2007) pushing the boundaries: improving services for people with heart failure. London: Commission for Healthcare Audit and Inspection. Cardiac Disease National Service Framework for WalesJune 2009: Standard 4 managing the care of patients with chronic heart failure NICE TA 197 Atrial Fibrillation – dronedarone: guidance. Scottish Intercollegiate Guidelines Network (2007) Management of Chronic Heart Disease British National Formulary No 62 Sept 2011. Centre for Disease Control (2006) Morbidity & Mortality Weekly Report, July 28, CDC: Atlanta 15. Development and initial validation of a simple clinical decision tool to predict the presence of heart failure in primary care Eur J Heart Fail. 2012 Sep;14(9):1000-8. Epub 2012 Jun 19. A - Setting up your team Achieving improvements that reduce harm, waste and variation at a whole organisation level needs a team approach: one person working alone, or groups of individuals working in an uncoordinated way will not achieve it and this applies equally at all organisational levels.Whether your improvement priorities relate to 1000 Lives Plus content areas, national intelligent targets or other local priorities, you need to consider three different dimensions in putting your team together:Identify a clinical lead (Lead GP, Practice Nurse)Identify a managerial lead (GP, Practice Manager, Practice Nurse)Clarify who is responsible for day to day leadership (Practice Manager)There may be one or more individuals on the team working in each dimension, and one individual may fill more than one role, but each component should be represented in order to achieve sustainable improvement.Clinical lead (GP, Practice Nurse)A senior clinician should always be given delegated accountability for a specific content area in this case Chronic Heart Failure; and all practice staff working on the changes should know who this is. This individual needs sufficient influence and authority to allocate the time and resources necessary for the work to be undertaken at the practice. It is essential that this individual has full authority over the areas involved in achieving the improvement aims. It is essential that practice staff have an understanding of the improvement methodology and to base conversations around the interpretation of improvement data. Reporting of progress to higher organisational levels should also use a consistent data format so that the Executive level leader can report to the Board on progress.Managerial lead (GP, Practice Manager or Practice Nurse)A clinical or technical expert is someone who has a full professional understanding of the processes in the content area. It is critical to have at least one such champion on the team who is intimately familiar with the roles, functions, and operations of the chronic heart failure content area. This person should be interested in driving change in the practice. (Identify individuals who are not afraid to try changes).Patients can provide expert advice to the improvement team within the practice, based on their experience of the system and the needs and wishes of patients. A patient with an interest in the improvement of the system can be a useful member of the team. Additional technical expertise may be provided by an expert on improvement methodology, who can help the team to determine what to measure, assist in the design of simple, effective measurement tools, and provide guidance on the design of tests.Day to day leadership (GP, Practice Manager or Practice Nurse)Frontline leaders will be the critical driving component of the practice team, assuring that changes are tested and overseeing data collection. It is important that this person understands not only the details of the system, but also the various effects of making changes in the system. They should have skills in improvement methods. This individual must also work effectively with the technical expert. They will be seen as a bridge between the organisation leadership and the day-to-day work and ensuring accurate and timely data collection for process and outcome measures related to the content area (Chronic Heart Failure).Characteristics of a good team memberIn selecting team members, you should always consider those who want to work on the project rather than trying to convince those that do not. Some useful questions to consider are the following:Is the person respected for their judgment by a range of staff?Do they enjoy a reputation as a team player?What is the person’s area of skill or technical proficiency? Are they an excellent listener? Is this person a good verbal communicator within and in front of groups?Is this person a problem-solver? Is this person disappointed with the current system and processes and passionately want to improve things?Is this person creative, innovative, and enthusiastic?Are they excited about change and new technology?Appendix B – Model for Improvement Driver DiagramAppendix C - PDSA Cycle - How to test changePDSA cycles are a process to assist you to make changes in your practice that can be used to support the implementation of the Heart Failure Driver Diagram. It is recommended to start small – one person, one setting, and one service provider.Even if something has been shown to work in other settings, take the time to do a small-scale trial. There are almost no ‘plug and play’ solutions that work in all situations. Testing allows us to adapt actions to particular settings. To test a new procedure or technique, the practice need to ‘plan, do, study and act’ as explained below.PlanPlan what you are going to do differently i.e., as a practice (or at least one GP and one other staff member), Choose an area where there is likely to be a significant gap between what you currently do and what evidence based guidelines suggest you do.Where the recommendations are consistent with your practice spend little or no time reading these, but where they diverge from usual practice explore these recommendations in more detail. DoCarry out the plan and collect information on what worked well and what issues need tackling.The first data collection will provide a ‘baseline’ of current performance (the starting part). The practice should plot the results on a chart, this will provide an ideal number of points to create a baseline or identify a trend. One way to get more points is to measure more frequently. The practice may find the information needed is not currently being collected. If so, start collecting the relevant information straight away.Displaying Observed Data in a time SequenceA run chart is a simple line graph which is used to track the performance of one (or more) steps in the process targeted for improvement across a defined period of time. Run charts are the visual expression of the process measure developed. Plotting the dots’ is very effective because it will help the practice spot trends and patterns displayed.For more on Run charts go to: ‘How to Improve’ document mentioned in the last paragraph has a section on run charts.StudyGather relevant team members as soon as possible after the test for a short informal meeting. Analyse the information gathered and review the aim of the new procedure or technique against what actually happened. Questions that need to be asked include:‘What is the information telling us?’What worked and what didn’t work?’‘What should be adopted, adapted, or abandoned?’ActUse this new knowledge to plan the next test. Agree the changes and amend the outcome measures if necessary.?Continue testing in this way, refining the new procedure or technique, until it is ready to be fully introduced. But, do it quickly (think in days, not weeks).Appendix C Process MeasuresTo assess the application of the driver diagram interventions, the following search criteria (as per audit + software) will be collectedand analysed by PCQIS and reported back to individual practices. Driver: Diagnosis and Investigation process measureAudit+DescriptorTotalCare Bundle OneRefer all patients with previous MI for echocardiography if not already done post MI 1AdenominatorAll patients with a record of MI ever1BAll patients who have an MI (ever) have had an echocardiogram recorded after the diagnosisPerform an ECG on all patients with suspected Heart Failure1CdenominatorAll patients with new diagnosis of HF due to LVSD (i.e. pick up HF and LVF/LVSD code) within the last 12 months (including MI patients)1EAll patients with new diagnosis of HF due to LVSD within the last 12 months and have ECG recorded within 2 months before or 2 months after the LVSD code (including MI patients)If ECG normal measure Plasma B-Type Natriuretic Peptide (BNP) If BNP raised refer for Echocardiogram1IAll patients with new LVSD diagnosis within the last 12 months and who have had a normal ECG (including MI patients) who have then had a BNP testIf ECG abnormal refer for echocardiographIJAll patients with new LVSD diagnosis within the last 12 months with an abnormal ECG who have had BNP test (including MI patients)Driver: Effective Drug Therapy process measureAudit+DescriptorTotalCare Bundle TwoTreat all who can tolerate therapy and for whom there are no contraindications, initially with an ACE/ARBs Inhibitor at low dose, titrating upwards to maximum2AdenominatorAll patients coded with Heart Failure and LVSD over 3 months since diagnosis 2BAll patients with HF and LVSD over 3 months who are being prescribed ACEI minus CI to ACEI Use licensed beta-blocker therapy for patients with Left Ventricular Systolic Dysfunction (LVSD), where there are no contra-indications and optimisation of dose to maximum tolerated (resting heart rate <65 b.p.m.2GAll patients with HF and LVSD over 3 months who are being prescribed beta-blocker therapy minus those who have a CI to beta-blockers Provide aldosterone antagonist to all pts who are NYHA 2-4 after optimisation of ACE1/ARBs and BB 2KdenominatorAll patients with HF and LVSD over 3 months who remain NYHA II-IV whilst taking ACEI/ARB2 and Beta Blockers 2LAll patients with HF and LVSD over 3 months who remain NYHA II-IV (whilst taking ACEI/ARB2 and Beta-Blockers) and who are being prescribed an aldosterone antagonist Driver: Effective clinician/ patient partnership process measureAudit+DescriptorTotalCare Bundle Three Patients are provided with verbal and written information about their condition. Patients are provided with a clear discharge plan from secondary care and an agreed self management plan3AAll patients with a diagnosis of HF due LVSD (over 3 months since diagnosis) who have a self management planDriver: Reducing the risk of infection process measureAudit+DescriptorTotalCare Bundle FourPatients with LVSD have an immunisation for pneumococcal pneumonia documentedPatients with LVSD who have an immunisation for influenza documented4AAll patients with a diagnosis of HF due LVSD (over 3 months since diagnosis) who have pneumococcal recorded (ever)4CAll patients with a diagnosis of HF due LVSD (over 3 months since diagnosis) who have had influenza vac in the last 18 months Appendix DRelevant suggested read codes for process measuresCare bundle oneDiagnosis & InvestigationRelevant suggested READ CodesPatients who have an MI recordedG30.. acute myocardial infarctionG32.. old myocardial infarctionG30..%Acute myocardial infarction (excluding G30A.)G35..% Subsequent myocardial infarctionG38..% Postoperative myocardial infarctionGyu34[X]Acute transmural myocardial infarction of unspecified siteGyu36[X]Subsequent myocardial infarction of unspecified sitePatients who have had a MI should have an Echocardiogram after the event8HQ7. Referral for echocardiography56F1. Echocardiogram declinedPatients with a new diagnosis of Heart Failure due to Left Ventricular Systolic Dysfunction (LVSD)G58..% Heart failure G581.% Left ventricular failure. G5yy9 Left ventricular systolic dysfunction21264 Heart failure resolvedPatients with LVSD who have had an ECG321B. 12 lead ECG32... Electrocardiography3211. ECG requested3215. ECG not donePatients with LVSD who have had an echocardiograph to confirm diagnosis5853.11 U-S heart scan585R. Echocardiogram normal5C20. Echocardiogram equivocal585g. Echocardiogram shows left ventricular diastolic dysfunction585f. Echocardiogram shows ventricular systolic dysfunctionPatients who have had a normal ECG3216. ECG normalR1431 [D]Electrocardiogram (ECG) abnormal32140 Ambulatory ECG normal321..% ECG-general3215. ECG not doneCare bundle 2Effective Drug TherapyRelevant suggested READ CodesPatients coded with Heart Failure due to Left Ventricular systolic dysfunction (LVSD)G58..% Heart failure G581.% Left ventricular failure. G5yy9 Left ventricular systolic dysfunctionPatients with LVSD prescribed ACE-inhibitor without contraindications for ACE-inhibitor recorded8I28 Angiotensin converting enzyme inhibitors contraindicatedU60C4 [X]Angiotensin-converting-enzyme inhibitors causing adverse effects in therapeutic use8I3P. Angiotensin II receptor antagonist14LM H/O Angiotensin converting enzyme inhibitor allergyZV14D[V] Personal history of ACE inhibitor allergy8I3D Angiotensin converting enzyme inhibitor declined8B6H. ACE target dose achieved8B6Q. Patient on maximal tolerated ACE inhibitor therapyTJC77 Adverse reaction to captoprilTJC78 Adverse reaction to enalaprilTJC79 Adverse reaction to ramipril8I74 Angiotensin converting enzyme inhibitors not toleratedbk3.. to bk5z. Losartan, Valsartan, Irbesartanbk7.. to bk9z. Candesartan, Telmisartan, EprosartanbkB..% OlmesartanbkD..% Amlodipine and ValsartanbkC..% Hydrochlorothiazide and Olmsartan8I64. Angiotensin converting enzyme inhibitor not indicatedbA..% Calcium channel blockers and ACEI bk6..% Trandolopril and verapamil hydrochloride14LN.00 ? H/O Angiotensin II receptor antagonist therapy (ARB) allergyU60CB00 [X] Angiotensin II receptor antagonist (ARB) causes adverse effects in therapeutic use.Patients with LVSD prescribed beta-blocker therapy without contraindications for beta-blocker recordedbd... BETA-ADRENOCEPTOR BLOCKERSTJC6. Adverse reaction to beta-blockersU60B7 [X]Beta-adrenoreceptor antagonists causing adverse effects in therapeutic use, not elsewhere classified242.. O/E - pulse ratebdf..% Bisoprolol fumarate bdl..% Carvedilol bdm..% Nebivolol 14LL. H/O beta-blocker allergy U60B9 Adverse reaction to bisoprolol U60BA Adverse reaction to carvedilol U60BB Adverse reaction to nebivolol ZV14C Personal history of beta-blocker allergy ZVu6i Personal history of allergy to bisoprolol ZVu6o Personal history of allergy to carvedilolZVu6q Personal history of allergy to nebivolol 8I26. Beta-blocker contraindicated 8I73. Beta-blocker not tolerated 8I2g. to 8I2i. Bisoprolol, Carvedilol, Nebivolol contraindicated 8I7K. to 8I7M. Bisoprolol, Carvedilol, Nebivolol not tolerated8IAS. to 8IAV. Bisoprolol, Carvedilol, Nebivolol therapy refused 8I36. Beta-blocker therapy refusedPatients with LVSD prescribed ACE1 or ARB2 and beta-blocker therapy and remain symptomatic (i.e. NYHA II-IV after optimisation)Patients who remain symptomatic (ie NYHA II-IV after optimisation) of prescribed aldosterone antagonistb43.. SPIRONOLACTONEb45..% EPLERENONE662fNYHA stage I662gNYHA stage II662hNYHA stage III662iNYHA stage IV8I2L. Spironolactone contraindicatedTJE44 Adverse reaction to spironolactone U60E1[X] Mineralocorticoid antagonists [aldosterone antagonists] causing adverse effects in therapeutic use8I3K0 Spironolactone declined8I3K. diuretic declinedCare Bundle 3Effective clinician/ patient partnership process measureRelevant suggested READ CodesPatients are provided with verbal and written information about their condition Patients are provided with a clear discharge plan from secondary care and an agreed self management plan8CMK. Has heart failure management plan8CL3. Heart failure care plan discussed with patientCare bundle 4Diagnosis & InvestigationRelevant suggested READ CodesPatients with LVSD have an immunisation for pneumococcal pneumonia documentedn4b.. PNEUMOCOCCAL VACCINE65720 Pneumococcal vaccination given 657P. Pneumococcal vaccine given by another providerU60J8. Pneumococcal vaccination causing adverse effect in therapeutic use ZV14G Personal history of pneumococcal vaccination allergy & 14LR. H/O: pneumococcal vaccine allergyPatients with LVSD have an immunisation for influenza in the last 18 months documented 4C65E... Influenza vaccinationn47..% Influenza vaccineZV048 Influenza vaccination14LJ. H/O influenza vaccination allergy U60K4 [X]Influenza vaccine causing adverse effects in therapeutic use ZV14F [V]Personal history of influenza vaccine allergy68NE.No consent - influenza imm.9OX5.Influenza vaccination declined14LJ.H/O: influenza vaccine allergy8I6D.Influenza vaccination not indicated8I2F.Influenza vaccination contraindicatedU60K4[X]Influenza vaccine causing adverse effects in therapeutic useAppendix E-Helpful ResourcesThe Traffic Light self-management tool, adapted from an Institute of Healthcare Improvement resource. Well evaluated by patients and carers, as a tool for recognising deterioration of their symptom control, and giving them confidence in obtaining advice and assistance from Specialist CHF Nurses.North Wales Cardiac Network Chronic Heart Failure Management Guidelines October 2012Heart Failure suspected – If no previous MI and normal ECG, exclude heart failure by measuring NTproBNP. Raisedlevels need echocardiogram based specialist assessment – within 2 weeks if severely elevated (>2,000ng/l).Heart Failure due to Left Ventricular Systolic DysfunctionProvide exercise-based rehabilitation and patient information to all. Offer to discuss prognosis and symptoms. with preserved ejection fraction Loop diuretic to relieve fluid retention+ACE-inhibitor, only check BP if postural symptoms. Check U&E after 1-week and increase doseorARB if truly intolerant to ACE-inhibitorGive diuretics to relieve congestion and fluid retention.Use loop diuretics at low to moderate dose together with ‘traffic light’ daily weighing.Add MRA – spironolactone 25-50mg daily for persisting oedema or dyspnoea (with renal function monitoring or specialist advice).Provide exercise-based rehabilitation and patient informationAim for tight control of risk factors e.g. HTN, DM, AF, obesity, raised cholesterolIntolerant to ACE-inhibitor and ARB even when starting low and going slow?Add hydralazine plus nitrate after introduction of BB and MRACardio-selective Beta Blocker“Start low and go slow”Avoid bradycardia <50 b.p.m.Do not initiate or increase dose if patient overloaded with fluid (with exception of fast AF)U&E monitoring week 1,2 & 4 then monthly for 3 months and three monthly thereafter for higher risk patientsAdd MRA (spironolactone 25-50mg daily) for persisting oedema or dyspnoea NYHA 2-4 (with renal function monitoring or specialist advice for CKD 4 and 5).Manage chronic conditions in line with NICE guidance:Use an ACEI for:HTN above 135/80MI: secondary preventionChronic kidney diseaseAtrial fibrillation rate control to resting rate < 80 b.p.m. with heart failure beta-blocker Use a statin following vascular risk assessment or inherited hyperlipidaemiaIf resting heart rate >70b.p.m and sinus rhythm despite full beta blockade, add ivabradine 5mg, increasing to 7.5mg bd (2.5mg in elderly)→ Refer for CRT +/- DefibrillatorQRS complex >150ms orQRS 120-149 ms plus echo dysynchrony echo EF< 35%Persisting symptoms? Discuss end of life issues in detailConsider adding:Digoxin low dose only if effective for relief of symptoms ORHydrazaline in combination with a nitrate especially in people of African or Caribbean origin with moderate to severe heart failure.Persisting NYHA III/IV Definition of Terms: HFheart failureHTN hypertensionMI myocardial infarctionMRAmineralocorticoid receptor antagonistBBbeta blockerACEIangiotensin converting enzyme inhibitorARBangiotensin receptor blockerLVSDleft ventricular systolic dysfunctioneGFRestimated glomerular filtration rateEF ejection fractionCRTcardiac resynchronisation therapyLVAD left ventricular assist deviceConsider:LVAD, transplantationEnd of life careNorth Wales Cardiac NetworkAtrial Fibrillation / Atrial Flutter Management Pathway (AF)New onset Atrial Fibrillation/Atrial Flutter with symptoms LVAD, All chronic disease clinics or clinicalpicion AFHistory and examinationManual pulse check If irregular pulse, perform an ECG to confirm Consider Heart Failure diagnosis requiring echo (not BNP) if ECG has abnormal QRS or T waves but slowly control heart rate first.556958510304145Further investigations:TFT, Persisting symptoms?C+ACE-inhibitor orARB if truly intolerant to ACE-inhibitore.g. candesartan, valsartan, in “Start low and go slow”ure ORDigoxin low dose only if effective for relief of symptoms ORHydrazaline in combination with a nitrate especially in peAn aldosterone antagonist licensed for treatment of heart failure e.g. spironolactone, especially in moderate to severe heart failure or MI in the past month ORople of African or Caribbean origin with moderate to severe heart failure.FBC,U&E, gQRS 120-149 ms plus dysyncny ocho EF< 35%lucose, manual BP Acute Medical admissionrecommendedStroke Risk Stratification/thromboprophylaxis for all patients ) or CHA2DS2VASc score (see over)Pharmacological cardioversionElectrical cardioversionAblation for flutterParoxysmalRecurrent episodes lasting usually <48 hours, max 7 daysLong standing or persistentNot self terminating, lasting > 7 days up to 12 months (or more with previous successful cardioversion)PermanentAccepted and longstandingConsider rhythm control if <65 years or symptomatic with AF, secondary to a treated corrected precipitant. Otherwise use rate controlRhythm controlIdentify trigger factors(e.g. alcohol) Attempt rate control only Management advice: Start standard ? blocker (bisoporolol or carvedilol) or rate limiting calcium antagonist (Verapamil or Diltiazem) if no LVSDTitrate to achieve resting ventricular rate of <80 b.p.m. or <110b.p.m. on exerciseAdd digoxin for resting rate control if resting ventricular rate persists >80 b.p.m.Management advice: Start standard ? blocker (bisoprolol or carvedilol) or rate limiting calcium antagonist (Verapamil or Diltiazem) if ? blocker not tolerated and no LVSDPlanned Electrical Cardioversion – use warfarin 3-4 weeks beforehand and at least 3 weeks after.Refer for specialist opinion if patient still symptomatic.Likely to be offered:Electrical cardioversion / EPS ablation so need warfarin initiation on referral. Amiodarone (permanent AF) or Dronedarone (non permanent AF) can be used (short term <6/12) to increase success of ECV.Pharmacological “pill in the pocket” therapy may be useful for paroxysmal events.The aim in all patients is to fully relieve all symptoms and for the stroke risk to be low.Key:Green = Primary Care Red = Secondary Care Yellow = Primary and Secondary Care North Wales Cardiac Network 2011Atrial Fibrillation / Atrial Flutter Management Pathway (AF)Who needs Warfarin? Usually those with at least 1 other risk factor for stroke. Annual risk of stroke is 1% per annum in the young and fit (5% over 5 years), increasing with age and other risk factors for all types of atrial fibrillation and flutter.The following links assist in the assessment of risk/benefit of warfarin treatment: Risk factors for stroke in non-valvular AFMajor risk factorsPrevious strokeTIA or systemic embolismAge ≥ 75 yearsClinically relevant non-majorrisk factorsCHF or moderate to severe LV systolic dysfunction (e.g. LV EF ≤ 40%)HypertensionDiabetes mellitusAge 65-74 yearsFemale sexVascular diseaseRisk factor-based point-based scoring system – CHA2DS2-VAScRisk FactorScoreCongestive heart failure/LV dysfunction1Hypertension1Age ≥ 75 years2Diabetes mellitus1Stroke/TIA/thrombo-embolism2Vascular disease1Age 65-74 years1Sex category (i.e. female sex)1Maximum score9Adjusted stroke rate according to CHA2DS2-VAScCHA2DS2-VASc scorePatients(n = 7329)Adjusted stroke rate (%/y)010%14221.3%212302.2%317303.2%417184.0%511596.7%66799.8%72949.6%8826.7%91415.2%Clinical characteristics comprising the HAS-BLED bleeding risk score; if >3, need strict control of INRLetterClinical characteristicPoints awardedHHypertension1AAbnormal renal and liver function ( 1 point each)1 or 2SStroke1BBleeding1LLabile INRs1EElderly (e.g. age > 65 years)1DDrugs or alcohol (1 point each)1 or 2Maximum 9 pointsPatients with mitral stenosis, prosthetic heart valves or risk score >1 usually require warfarin. Where antithrombotic therapy is given:The most effective treatment (reduces stroke risk by 2/3), is adjusted-dose Warfarin (target INR 2.5, range 2.0 to 3.0). USE WHOLE mg DOSES.Where Warfarin is not indicated, give aspirin 75 to 300 mg/day +/- clopidogrel 75mg daily (both reduce stroke risk additively by 1/5 each). Consider gastroprotection.If Warfarin is appropriate, do not co administer aspirin purely for thromboprophylaxis, as it provides no additional benefit. Aspirin may be continued if clearly indicated separately.Clopidogrel has a similar benefit to Aspirin but increases the bleeding risk when used concurrently.Initiation of Warfarin:There is no need to achieve anticoagulation rapidly; a slow loading regimen is safe and achieves therapeutic coagulation in the majority of people within 3-4 weeks. Ensure appropriate monitoring of INR using clinical support software. See BNF for potential drug interactions.Atrial Flutter: Rate and rhythm control can be more difficult DC cardioversion and / or ablation are more successful so earlier referral is indicated.Appendix F – GlossaryAcronym / Term DescriptionACEI Angiotensin-converting enzyme inhibitors (treatment for high blood pressure and heart failure).AF Atrial fibrillation (irregularly irregular rhythm of the heart).ARB Angiotensin receptor blocker (treatment for high blood pressure and heart failure)BB Beta blocker (treatment for heart rhythm, angina and heart attacks, high blood pressure and heart failure)BNPB-type natriuretic peptide (a protein substance secreted from the heart wall especially when stretched or when the pressure within it has risen)BP Blood pressure.CHD Coronary heart disease.CHF Chronic heart failure.ECGElectrocardiogram (Recording of the electrical activity of the heart)ECHO Echocardiography (is a diagnostic test which uses ultrasound waves to make images of the heart chambers, valves and surrounding structures. It can measure cardiac output and is a sensitive test for inflammation around the heart (pericarditis). It can also be used to detect abnormal anatomy or infections of the heart valves. HF Heart failure.LVADs Left ventricular assist devices (Sophisticated device, implanted surgically to help a badly failing heart, to pump blood into the circulation)LVEF Left ventricular ejection fraction (the percentage of the volume of the blood that leaves the heart with each beat, this is a measure of the pumping function of the left pumping chamber of the heart)LVSD Left ventricular systolic dysfunction (The condition where the left pumping chambers ability to pump is impaired. This is characterised by low left ventricular ejection fraction, and leads to heart failure)MI Myocardial infarction (Heart attack)NICE National Institute for Health and Clinical ExcellenceNP Natriuretic peptide (A protein substance secreted by the wall of the heart when it is stretched or under increased pressure. It has several forms)NSF National Service Framework. Policies set out by the National Health Service to clearly define standards of care for major medical issuesNTproBNP N-terminal pro-B-type natriuretic peptide (One of the natriuretic peptides, protein substances secreted by the wall of the heart when it is stretched or under increased pressure. It has several forms)NYHANew York Heart Association (functional classification): (These allow an assessment of the patients ability to carry out exercise before they develop their symptoms ................
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