Aims and objectives:
The Queen’s Medical Centre Heart Failure Nursing Service comprises of three specialist nurses supported by a Consultant Cardiologist. The team delivers an inpatient programme of heart failure education accompanied by telephone contact and outpatient follow-up, with the aim of improving the health related outcomes and rate of re-admission common to this patient group.
The objectives of the service are to:
Use appropriately targeted education to empower patients and their carers to manage this chronic disease effectively following hospital discharge.
Train patients and their carers in the use of specific disease management tools (e.g. daily weight monitoring diaries and renal function charts designed by the team) to ensure they recognise signs and symptoms indicative of deterioration and respond accordingly.
Act as a point of contact following hospital discharge, providing patients with continued support via telephone communication and expediting clinic review if necessary.
Offer non-specialist personnel caring for heart failure patients practical advice and support to ensure patients receive the highest possible standard of nursing care and medical management during their hospitalisation.
Facilitate optimisation of anti-failure therapies in the outpatient setting.
Employ teaching as a means of raising disease awareness among health care professionals of all grades across both primary and secondary care interfaces.
The work of the Heart Failure Nursing Service supports national strategy (The NHS Improvement Plan 2004; National Standards Local Action: health and social care standards and planning framework 2004; National Service Frameworks for Coronary Heart Disease 2000 and Older People) by ensuring that patients with this long term condition receive the personalised care and educational input necessary to live healthier lives. Through the development of close links within the health and social care community, the team are able to offer patients rapid and flexible access into appropriate services, which is in keeping with local strategy (A Strategic Direction for Hospital Services in Nottingham, 2001-2006).
Support for the change:
The release of our operational policy in 2002 to the Trust’s consultants and GP Practices in Broxtowe, Hucknall, Gedling, City and Erewash PCT's, served to introduce the service to potential users and was supported by a web-site and e-mail address for on-line specialist advice. Efforts since to embed and encourage use of the service within the hospital have included poster campaigns and teaching in a variety of forums ranging from Coronary Care/Medical High Dependency Training Courses to Junior Doctor Induction Days.
A recent strategy to promote service uptake is the development of an outreach facility championed by the hospital’s Clinical Lead for Heart Failure. New heart failure patients throughout the hospital can now be identified via diagnostic imaging. Service provision is therefore no longer dependent upon clinician or nurse referral of patients allowing for greater equality of care with more patients receiving the benefits of educative intervention.
In terms of strategic influencing, the team actively drive improvements in the management of heart failure patients within primary care by participating as Heart Save Trainers on the National Cardiovascular Training Programme for community based health professionals.
Patient and public influence:
Continuous audit of service provision has allowed the team to monitor trends in the needs of service users. The high number of in-patients referred for simple educative intervention positively influenced the team’s recent decision to extend services to an outreach facility. We have also noted a gradual rise in requests for advice on the pharmacological management of complex cases. The team have sought additional training to meet this emerging demand and ensure that in-patients receive optimal therapies and appropriate monitoring.
Despite lacking the resources necessary to provide in-patients with community support immediately following discharge, the team have designed a flexible service that can be tailored around the needs of individual patients. Telephone contact is employed to support and provide advice to patients during this high risk period and patients are encouraged to contact the service at any time should their condition deteriorate. Outpatient review can then be arranged within a matter of days depending upon the urgency of patient needs and unnecessary hospitalisation avoided.
Impact on the workforce:
In January 2001 Queen’s Medical Centre appointed a single Heart Failure Specialist Nurse to develop the role within secondary care. Two years later funding was procured for two additional nurses enabling service provision to extend beyond the outpatient setting to include in-patients.
Measuring the results:
The work of the Heart Failure Nursing Service is standards-driven with an emphasis on continuous improvement. Data relating to patient and service user characteristics, clinical outcomes and other quantitative aspects of service provision are recorded on a bespoke ACCESS database for the purposes of clinical audit. Qualitative evaluation of the service has taken the form of a patient survey. At present our service is unique within Trent Region but we have compared our re-admission rate against that of the Trust.
Improved performance:
Data indicate outstanding performance with our inpatient population - a near 50% reduction of patient readmission rates when compared to in-patients without service contact. None of our patients were re-admitted within 24 hours of hospital discharge compared to 14% of all other in-patients. The maximum number of readmissions per patient was also considerably less (2 as opposed to 10).
Reflecting diversity:
Disease monitoring tools designed by the team have been produced in Urdu and Punjabi and we monitor ethnicity of referrals to ensure fair representation.
The majority of our patients are aged 65 years and over and for our more frail elderly the team work in close collaboration with a hospital geriatrician to co-ordinate patient care across specialities which helps to avoid other adverse outcomes such as falls and incontinence.
Relatively young patients with cardiomyopathies also come under our care. This patient group often have a distinctly different set of needs to those of older patients particularly with regard to concerns surrounding employment, family planning, lifestyle modification and sexual functioning. Our armoury of literature reflects our recognition of the importance of these issues and is expanded upon each time a novel query is raised during the course of nurse/patient interaction.
Sharing the learning:
We have produced a website shared with the CHD Collaborative showcasing our patient information literature and this has prompted external interest from across the UK.
Outstanding features:
Literature produced to support patient education demonstrates innovation and imagination. Enthusiasm and relentless optimism capture the essence of the team.
