Role of BHF nurse in community/Heart Failure Case Study

BHF Heart
What is the Heart Failure Service?
Aims of the service
Delivery of the service
What do we do?
Training and supervision
Referrals and referral criteria
Discharge from the service
Case study
What is the Heart Failure Service?
The British Heart Foundation currently supports over
400 Heart Failure Specialist Nurses nationwide.
“Heart Failure Specialist Nurses provide care and
advice to heart failure patients in their own home,
helping to keep them out of hospital and improving
their quality of life.”
What is the Heart failure Service?
“They forge strong bonds with patients and their
families, understanding their needs and concerns.
They co-ordinate a shared care approach with other
clinical and social services.”
(BHF website
Aims of the Heart Failure Service
• Promote independence of educate patients so they
have a good understanding of their disease and
• Promote self-management to enable patients to
achieve optimum health and quality of life;
• Optimise research-bases treatments/medicines to
prevent reduce mortality and increase quality of life,
and prevent unnecessary hospital admissions;
Aims of the Heart Failure Service
• Regular review and availability of heart failure nurse
via telephone, thereby reducing GP visits;
• Arrange appropriate palliative care to ensure
comfort and symptom control at the end stages of
the disease.
Delivery of the Service
2.6 FTE Heart Failure Specialist Nurses
Based at Oak Farm Clinic, Long Lane, Hillingdon
Home visits
3 Community Clinics
– North – Eastcote Health Centre
– Central – Uxbridge Community Health Centre
– South – HESA Community Health Centre, Hayes
Nature of Service Provision
Initial assessment and medication review;
Symptom assessment;
Education about disease, symptoms and treatments;
Promotion of self management and advice about
factors affecting symptoms;
• Education about controlling symptoms;
• Optimisation of research-based medicines, including
necessary blood tests;
• Regular review;
Nature of Service Provision
• Referral to other appropriate services e.g.:
physiotherapy, Diabetes Specialist Nurses, District
Nurses, Rapid Response, Social Services, Palliative
Care Team, GP;
• Health Promotion e.g.: smoking cessation;
• Referral to Cardiac Rehabilitation;
• Phone ‘helpline’.
Guidelines Used
• NICE Guidelines for Chronic heart failure:
management of chronic heart failure in adults in
primary and secondary care. (NICE Guidance CG108,
August 2010)
• ESC Guidelines for the diagnosis and treatment of
acute and chronic heart failure 2012 (European Heart
Journal (2012) 33, 1787-1847)
Training and Clinical Supervision
• Clinical Supervision monthly with Dr Simon Dubrey,
Consultant Cardiologist at Hillingdon Hospital;
• Consultant, registrar, and Heart Failure Specialist
Nurse at Hillingdon Hospital;
• Cardiology team and Heart Failure Specialist Nurse
at Watford General Hospital and Northwick Park
• Monthly Heart Failure MDT meeting at Northwick
Park Hospital with Dr Hugh Bethell and team;
Training and Clinical Supervision
• BHF Regional Conferences and Study Days;
• Pan London Heart Failure Nurse meetings;
• Heart Failure Course – Glasgow Caledonian
• British Journal of Cardiac Nursing;
• GP Practice MDT meetings.
Referral Criteria
• Diagnosis of left ventricular systolic dysfunction
(LVSD) with objective evidence e.g.:
echocardiogram, cardiac MRI;
• Heart Failure is their main clinical problem;
• Registered with a Hillingdon GP practice;
• Willing to accept the added support of the service.
• Patients may be discharged from the service if their
medical therapy is optimised and their condition is
stable, and they are able to self manage their
• Non-compliance/DNA;
• Patient request;
• GP request.
Case Study
• Mrs X 85 years old, lives alone, history of falls
• Admitted to hospital under COTE with vomiting and
weight loss, bilateral leg oedema to the knees.
• Deranged LFTs and INR > 20
• Acute on chronic kidney injury
• Echo: dilated LV with severe impairment of systolic
function. EF 10%
Medical history
AF – on warfarin
Alcohol intake approximately 28 units/week
In-hospital treatment
INR corrected with Vitamin K and FFP
IV fluids
Antibiotics for cellulitis to left leg
Liver screen serum blood test showed no apparent cause of
deranged LFTs – probable congestion due to CCF
Once U&E’s and LFT’s improved - started on treatment for
heart failure including ACE inhibitor and diuretic
Discharged home with care package
Ramipril 2.5mg od
Bumetanide 2mg od
Digoxin 125mcg od
Thiamine and Vitamin B compound
Warfarin stopped and aspirin started + omeprazole
Initial assessment
BP 118/55, HR 65 (AF), Weight 79kg
Lungs: wheezes throughout, no crackles. Patient is
breathless on minimal exertion with cough
Pitting oedema to knees – skin had broken down so
dressings to these areas
Initial blood test: eGFR 54, normal LFT’s
Poor memory, mild dementia.
Initial management
Increase in diuretic dose
Dosette box for medications
Repeat blood test for U&E’s after 1 week
Incontinence due to urinary frequency secondary to increase
in diuretics - Referred to district nurse team for continence
assessment and provision of pads.
Good diuresis with increase in diuretics. Renal function
remained stable.
Patient reported breathing improved a lot. Chest clear and
cough resolved.
Oedema to legs resolved and wounds dry.
Ongoing management
Uptitration of ACE inhibitor in line with NICE Guidelines monitoring patient after each dose change including BP and
Reduction in diuretic dose once oedema resolved
Digoxin dose reduced due to bradycardia (no beta blocker)
Any Questions?