Project Name: Collaborative Working Service improvement for the detection and treatment of Heart Failure (“HF”) in secondary care (“Integrated Nurse Programme”)
Project Summary:
The Project main objective is to improve the quality of care delivered to HF patients under the care of the Hospital in line with NICE guidance. The Project will involve:
The introduction of the hospital-based specialist HF service through the deployment of an “in-reach “nurse with the purpose of identifying and triaging HF patients (both at acute medical receiving units and non-Cardiology departments). This is to ensure they can be appropriately referred to the relevant Cardiology service, receive specialist HF input and aid in coordinating the discharge of patients to ensure continuous appropriate care for HF patients after their discharge from hospital.
The implementation of a weekly Multi-Disciplinary Team (“MDT”) care for HF patients delivered by HF HCP specialists. The MDT will review and deliver integrated patient care which may include interventions such as clinical review, medicines management, cardiac rehabilitation, education, self-monitoring and management, telemonitoring or telephone support for the HF patients identified as described at point (1) above.
Planned Milestones:
- Kick Off Meeting
- Collection of baseline data, in line with the Project Outcome Measures & Data Collection table
- Confirmation of recruitment of Band 8a Nurse Specialist & Band 4 admin
- Confirmation of clinical and operational pathway, policy and protocol creation, and readiness to begin the clinical activity
- Collection & submission of 3 months clinical activity data & Project Review meeting to discuss project progress.
- Collection & submission of 6 months clinical activity data &Project Review meeting to discuss project progress.
- Collection & submission of 9 months clinical activity data & Project Review meeting to discuss project progress.
- Collection & submission of 12 months clinical activity data & Project Review meeting to discuss project progress.
- Development of business case
- Submission of business case by the CW Partner HF team to relevant body within the NHS Board
- Submit final CWP report to Novartis within 3 months completion of the clinical work
Expected Benefits:
Anticipated benefits to patients:
- Improved access to optimal diagnosis and treatment.
- More equitable and consistent care and access to care; and
- Enhanced experience for HF patients and carers who live with HF due to access to HF specialist service.
Anticipated benefits to the CW Partner:
- Increased overall quality of care and improve equity of access to specialist care for patients with HF.
- Improved patient flow and reduced total number of inpatient bed days due to HF;
- Increased proportion of patients with HF being managed in accordance with NICE guideline standards; and
- Insight into benefits of an inpatient HF service which may inform ongoing redesign and workforce planning.
Anticiapted benefits to Novartis:
- Further opportunities for the appropriate use of cardiology licensed medicines in line with NICE guidelines, including Novartis’s medicine.
- Improved reputation.
- Improved professional and transparent relationship and trust between Novartis and the NHS.
Start Date & Duration: December 2023 for 18 months
UK2312146291
Project Name: Service improvement for the detection and treatment of Heart Failure (“HF”) in secondary care, Integrated Nurse Programme
Organisation(s): Stoke Mandeville NHS Trust
Completion Date: June 2025
Outcome Summary:
Improved outcomes in parameters highlighted in the National Institute for Cardiovascular Outcomes (NICOR), including an increase in the number of patients receiving appropriate combination of medications. This project has created greater awareness and improved network development across the Trust for heart failure.
Key Project Outcomes Data:
A total of 242 patients had been seen via this new service,the remaining patients received appropriate care from the cardiology team. Significant improvements made in parameters set out in the National Institute for Cardiovascular Outcomes (NICOR), such as average percentage of HF specialist input (88.1% v 43.2% at baseline), average percentage of patients with echocardiogram access (85.4% v 60.2% at baseline) and average percentage of patients receiving HF Nurse follow up (69.9% v 42.9% at baseline).
Outcomes:
The prevalence of heart failure patients in the region is approximately 5,400 with 500 patients per year requiring hospitalisation. Prior to this collaborative working project, the Trust recorded lower than national average for the following measures:
- Patients seen by a heart failure specialist
- patients being discharged on appropriate combination of medications
- follow up with heart failure specialist
Aims and objectives of new service:
- Earlier identification of heart failure patients
- Improve delivery of evidence-based Heart Failure (HF) drug therapies
- Provide early post discharge review at 2 weeks and transition to the community heart failure specialist nurse team.
- Increase revenue to BHT (through NHS Best Practice Tariff)
- Build a business case to have permanent heart failure nurse in reach service at SMH
Results (average reported percentages across project milestones v baseline):
- Percentage specialist follow up: 57.6% v 33.7%
- Percentage input from specialist: 88.1% v 43.2%
- Percentage of patients with echo access: 85.4% v 60.2%
- Percentage of patients receiving discharge plan: 96.3% v 96.9%
- Percentage of patients receiving HF nurse follow up: 69.9% v 42.9%
Other observations and developments:
- There was an average increase of patients receiving appropriate combinations of medications throughout the project. These include:
- Angiotensin-converting enzyme inhibitors (ACE)
- angiotensin receptor/Neprilysin inhibitor (ARNI)
- Angiotensin receptor blockers (ARB)
- Beta-blockers (BB)
- Mineralocorticoid receptor antagonists (MRA)
- Sodium-glucose co-transporter 2 (SGLT2)
- Those who were not reviewed were still reviewed within 2 weeks of being discharged
- Not all patients were eligible for follow up
- The work carried out resulted in employment of a 0.2 WTE admin support for service, releasing more nurse time
- Local and regional presentations and teaching carried out including promotion of heart failure awareness week
- Clinical lead heart failure consultant in post Nov 2024 to fill vacancy in first half of project
- Weekly ward rounds and MDTs implemented
- The work created a link up with hospital at home team with daily MDTs
- Involvement in Innovation and research team and active role in subcutaneous furosemide trial
Quote From Partner:
“This project has provided the opportunity to facilitate the early identification of heart failure patients and provide clinical expertise and operational leadership for adult patients with acute decompensating heart failure within the inpatient setting and following discharge. This was a well needed service which data analysis revealed significant under-performance in Stoke Mandeville Hospital in contrast to much better performance at Wycombe Hospital which has on-site cardiology team presence. This was based on measuring NICOR standards such as heart failure specialist input, being discharged on appropriate medications, and having timely follow up post discharge, which have been shown to contribute to reducing mortality and improving quality of life. More recent data post service implementation has demonstrated a significant improvement in compliance to all these areas.
The service has acknowledged limitations with only one heart failure specialist nurse in post and not all referrals can be reviewed. This is a time limited project, and we have now created a business case to enable sustainability of this service and expansion of the team. Further study will involve looking at readmission rates to help greater analysis of the impact of the in-reach heart failure service.”
Louise Collier, Heart Failure Specialist Nurse, Stoke Manderville NHS Trust
Conclusion:
Significant improvements have been made in parameters measured in NICOR, thereby achieving the objectives set out at the start of the project. 176 patients have been successfully identified and treated via the new service and the work carried out has led to an increased awareness of HF both across departments in the Trust, and also in the community. Future plans for the service include:
- Development of a business case for sustainability
- 30-day readmission audit (in progress)
- Other planned audits – inpatient mortality, number of heart failure admissions compared to referrals, length of stay
- Development of patient feedback forms
FA-11463564 | June 2025