Policy for the Approval of Clinical Guidelines, Protocols, Policies and

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Policy for the Approval of Clinical Guidelines, Protocols, Policies and
BUCKINGHAMSHIRE HEALTHCARE NHS TRUST
GUIDELINE 707FM.1
Approved by the Clinical Guidelines Subgroup of the Drug and Therapeutics
Committee May 2009
Clinical Guideline forINVESTIGATION AND MANAGEMENT OF HEART FAILURE WITHIN PRIMARY
CARE
For use in (clinical
areas):
For use by (staff
groups):
For use for (patients):
Author/s
Approved by
Date of Approval
Review Date
Guideline Number
Guideline 707FM.1
Primary Care
GPs and Specialist Cardiac Care Nurses
Patients with Heart Failure
Dr P Clifford, Dr N Reidy, Dr S Stamp, Dr S
Watteeux, J Godden, J McEwan, D Nicholls
Area Prescribing Committee and PEC
March 2011
To be assigned
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DOCUMENT CONTROL SUMMARY
GUIDELINES
Investigation and Management of Heart
Failure within Primary Care
Guidelines for the Investigation and
Management of Heart Failure within
Primary Care in Mid and South Bucks
approved by Buckinghamshire Area
Prescribing Committee 5 July 2006
Title
Supercedes
Author(s)
Dr P Clifford, Dr N Reidy, Dr S Stamp, Dr
S Watteeux, J Godden, J McEwan, D
Nicholls
Lead Development
Group/Committee
Bucks PCT Cardiology Demand
Management Workstream
Other contributors
Dr P Ramrakha, Dr F Hami, Dr G Payne,
Dr S Pillau, J Butterworth
Status
Draft
Version/Issue No.
Version 4
Approved by APC
Pending Approval April 2009
Approved by PEC
Pending Approval April 2009
Review Date
March 2011
Who will undertake the review
PCT lead for Cardiology
Circulated through
Intranet
VERSION CONTROL SUMMARY
Version
1
2
Date
5 July 2006
July 2007
Status
Approved
Draft
2
Aug 2007
3
March 2009
4
May 2009
Draft for
approval
Draft for
approval
Draft for
approval
Guideline 707FM.1
Comment/Changes
By Bucks Area Prescribing Committee
To be checked by workstream prior to
submission to CEG via PCT Head of Quality
Submitted to CEG via Head of Quality
No changes made from version 2. Version 2 never ratified
by PCT. Would like ratification by APC and PEC.
Changes made to meet BHT guideline standard and
comply with Bucks drug formulary
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Investigation and Management of Heart Failure within Primary Care
Clear guidelines for the management of Chronic Heart Failure have been laid
out in the NICE Clinical Guideline 5 July 2003. This local guideline aims to
ensure that all patients with suspected heart failure will be offered appropriate
investigations, recommended treatments and regular specified monitoring of
their condition. The guideline seeks to ensure smooth transfer of care
between all areas of the heart failure service across primary and secondary
care.
Recommendations and procedures
Diagnosis of heart failure must be confirmed by echocardiography. Only
patients whose diagnosis is confirmed should be managed within this
guideline.
Guideline 707FM.1
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GUIDELINES FOR THE INVESTIGATION AND MANAGEMENT OF HEART
FAILURE WITHIN PRIMARY CARE IN BUCKS
Contents
Page Number
Introduction / Diagnosis / Classification
1.
Lifestyle
2.0
Drug Therapy
2.1
6
Diuretics
Treatment Algorithm
7
Diuretic Flow Chart
8
2.2
Treatment of
Left
Ventricular
Systolic
Dysfunction
5
ACE Inhibitors
ACE Inhibitor Flow Chart
2.3
Beta Blockers
2.4
Spironolactone
2.5
Digoxin
9
10
11
Beta Blocker Flow Chart
12
Spironolactone Flow Chart
13
3.0
Monitoring
4.0
Referral
4.1
Heart Failure Nursing Service
4.2
Cardiology
14
Palliative Care Provision for end Stage Heart Failure
Patients
15
Limitations of the Role of Palliative Care in Heart Failure
16
Guideline 707FM.1
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Introduction
Clear guidelines for the management of Chronic Heart Failure have been laid out in
the NICE Clinical Guideline 5 July 2003. This local guideline aims to ensure that all
patients with suspected heart failure will be offered appropriate investigations,
recommended treatments and regular specified monitoring of their condition. The
guideline seeks to ensure smooth transfer of care between all areas of the heart
failure service across primary and secondary care.
Diagnosis
Alternative diagnoses must be considered as there are many conditions presenting
with similar symptoms:
• Obesity
• COPD
• Asthma
• Venous insufficiency in lower limbs
• Drug-induced ankle swelling (eg dihydropyridine calcium channel blockers)
• Drug induced fluid retention ( eg NSAIDs)
• Hypoalbuminaemia
• Intrinsic renal or hepatic disease
• Severe anaemia or thyroid disease
• Bilateral renal artery stenosis
Recommended tests, which may help to exclude the above include:
• Chest X ray
• ECG
• Spirometry/peak flow
• Full blood count
• Urea, electrolytes, and creatinine
• Liver function test
• Glucose
• Thyroid function tests
• Lipids
Diagnosis of heart failure must be confirmed by echocardiography. Only
patients whose diagnosis is confirmed should be managed within this
guideline. All new heart failure patients for whom revascularisation might be
appropriate, should have a minimum of one outpatient consultation with a
cardiologist.
European Society of Cardiology criteria for the diagnosis of heart failure:
• appropriate symptoms of heart failure
• objective evidence of cardiac dysfunction on echo and ECG
• appropriate response to relevant treatment in cases of doubt
Classification
New York Heart Association classification:
Grade I
Grade II
Grade III
Grade IV
No limitation, ordinary exercise causes no limitation
Slight limitation of physical activity, comfortable at rest
Marked limitation of physical activity
Inability to carry out any activity without symptoms
Guideline 707FM.1
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TREATMENT OF LEFT VENTRICULAR SYSTOLIC DYSFUNCTION
Patients and carers should be taught about heart failure, including a discussion of the
diagnosis and prognosis. They should be involved in the monitoring and self
management of this condition wherever possible.
1.
Lifestyle
Advice on the following should be given by a heart failure specialist (GP, nurse or
cardiologist):
• Diet
• Tailored exercise programme
• Smoking cessation
• Alcohol
• Vaccination. Patients should be offered a pneumococcal vaccine and annual
influenza vaccine.
• Weight monitoring, fluid balance, dry weight
2.
Drug Therapy
It is the responsibility of the individual prescriber to check the dosage of medication.
Treatment should be tailored to the individual patient using the following protocols as
a guide.
2.1
Diuretics
Loop diuretics are first line treatment for the control of congestive symptoms and fluid
retention.
Monitoring will be carried out in primary care unless the patient is an inpatient in
secondary care.
Monitoring will consist of U&E & creatinine:
• Prior to treatment
• 1 week after starting treatment
• 1 week after any sustained increase in dose
If symptoms persist despite maximal doses of loop diuretics a thiazide can be added
(ie metolazone 2.5mg on alternate days).
If the patient remains oedematous despite the addition of a thiazide consider referral
to heart failure community matron or cardiologist, if this has not already been done.
Guideline 707FM.1
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TREATMENT OF LEFT VENTRICULAR SYSTOLIC DYSFUNCTION ALGORITHM
•
•
•
•
Treatment of LVSD
Confirm diagnosis by echocardiography
Confirm aetiology (especially exclude coronary disease)
Discontinue aggravating drugs, e.g. NSAIDs
Address non-pharmacological and lifestyle measures
Signs of fluid
retention
Patient
Stable?
Yes
No
Loop diuretic in
appropriate dose
(start low e.g.
furosemide 40mg
and increase as
flow chart)
Angiotensin converting enzyme inhibitor / A2
receptor blocker and (1) β-blocker (2)
Atrial fibrillation
Angina
• Warfarin or aspirin (unless
contraindicated) and/or
• Digoxin and/or
• Consider referral (3)
• Consider β-blocker
if not already given
• Nitrates
• Referral to
specialist (4)
Symptoms relieved
(NYHA class I-III)
Persisting symptoms
no fluid retention
(NYHA class III/IV)
• Digoxin and/or
• Spironolactone (5)
• Consider referral (6)
1.
See ACE inhibitor flowsheet
2.
Mild to moderate heart failure. Caution required. Specialist
supervision by cardiology community matron required. See βblocker protocol.
3.
DC cardioversion may be indicated + amiodarone.
4.
Coronary angiography and revascularisation may be helpful.
5.
Severe heart failure. Care needed to avoid hyperkalaemia,
especially if creatinine raised.
6.
Other specialist therapy may be helpful.
Guideline 707FM.1
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Persisting fluid retention
• Consider spironolactone
(5)
• Increase diuretic
• Consider digoxin and/or
• Consider thiazide (ie
metolazone 2.5mg on
alternate days)
• Consider referral (6)
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DIURETIC FLOW CHART
Deteriorating HF symptoms
Stable HF symptoms
Daily Weight increases 1kg above dry weight
Daily weight decreases 1kg below dry
weight
Sustained over 2-3 days
Sustained over 2-3 days
With/without symptoms of increased dyspnoea
and / or increased peripheral oedema
No symptoms of increased dyspnoea or
peripheral oedema
Stable blood chemistry
May also have symptoms of thirst,
dizziness, or generally feeling washed out
Check U&Es for raised creatinine
Increase dose of:
Furosemide:
Current dose
40mg od
80mg od
80mg & 40mg
Decrease dose of:
Increased to
80mg od
80mg & 40mg
80mg bd
Furosemide:
Current dose
80mg bd
80mg & 40mg
80mg od
Decreased to
80mg & 40mg
80mg od
40mg od
Bumetanide:
Current dose
5mg od
4mg od
3mg od
2mg od
Decreased to
4mg od
3mg od
2mg od
1mg od
(1mg bumetinide = 40mg furosemide)
Bumetanide
(Dose may be split am/pm)
Current dose
Increased to
1mg od
2mg od
2mg od
3mg od
3mg od
4mg od
4mg od
* 5mg od
Patient’s symptoms should be reviewed for 3
days following a diuretic reduction for signs of
deterioration.
* Following cardiology advice.
Patient’s symptoms should be reviewed in 3 days
if an increased diuretic dose is sustained then
blood chemistry should be checked after 1 week.
The goal of diuretic treatment should be to achieve a dry weight using the
lowest diuretic possible
If symptoms of dyspnoea and
oedema persist a thiazide may
be added to the loop diuretic
•
•
•
Consider referral
Guideline 707FM.1
•
A flexible diuretic regime should be encouraged to suit patient’s needs.
Daily timing need not be fixed.
Observe for signs of over treatment: dizziness/light-headedness/fatigue
(washed out feeling), uraemia and gout.
Over-treatment can occur if the patient develops diarrhoea, vomiting. Hot
weather and reduced fluid intake can also cause dehydration.
Non-specific symptoms may occur in the elderly, such as confusion,
impaired mobility, falls and urinary incontinence.
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2.2
Ace Inhibitors
All patients should be considered for treatment with an ACE inhibitor. This can be
initiated within primary care unless specialist advice is required (See ACE inhibitor
algorithm). Treatment should be started at the lowest dose and be titrated up at 2
weekly intervals, aim for the target dose or the highest tolerated dose. Titration is the
responsibility of the GP.
ACE
Captopril
Lisinopril
Ramipril
Starting Dose
6.25mg tds
2.5mg od
2.5mg od
Target dose
50-100mg tds
30-35mg od
10mg od
Monitoring during titration phase will be carried out by the GP. Routine monitoring is
the responsibility of the GP. Monitoring will consist of U&E & creatinine and blood
pressure:
• Prior to treatment
• 1 week after starting treatment
• 1 week after increasing dose
• 3 and 6 months after initiation
• 6 monthly for routine monitoring
Problem Solving
Symptomatic Hypotension
• Consider stopping / reducing nitrates, calcium channel blockers or other
vasodilators
• If no signs of fluid retention consider reducing diuretic dose
Cough
• Cough is common in patients with chronic heart failure
• Exclude pulmonary oedema if new or worsening cough develops
• If ACE inhibitor induced cough consider substitution with an angiotensin II
receptor antagonist. Candesartan is to be used first line (starting dose 4mg od
and target dose 32mg od, titrated every 2 weeks and monitored as for ACE
inhibitor).
Renal impairment
• Some rise in urea, creatinine and potassium is to be expected after initiation.
• An increase in creatinine of up to 50% above baseline, or to 200micromol/l, which
ever is the smaller is acceptable.
• An increase in K to 5.9mmol/l is acceptable.
• Consider stopping any concomitant nephro toxic drugs, potassium sparing drugs,
non-essential vasodilators and if no signs of congestion, reducing diuretic.
• If renal impairment persists halve dose of ACE and recheck blood chemistry in a
week.
• If urea increases by 10mmol/l or to 20mmol/l or the creatinine increases by
100micromol/l or to 300micromol/l seek specialist advice and stop ACE.
• If potassium rises above 6 mmol/l stop ACE and seek specialist advice.
Guideline 707FM.1
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ACE INHIBITOR FLOW CHART
•
•
•
•
Confirm left ventricular systolic dysfunction.
Confirm no contraindications.
Check urea, creatinine, sodium and potassium
Check BP
Suitable for treatment in
community without
specialist advice
No
•
Specialist advice may be required before
starting ACE inhibitor
If any of the following
•
•
•
•
•
•
•
Creatinine >200micromol/l
•
•
e.g. peripheral vascular disease
•
•
•
•
•
Urea >12mmol/l
Sodium <130mmol/l
Potassium >5.5mmol/l
Systolic arterial pressure <100mmHg
Diuretic dose >frusemide 80mg/day
Known or suspected renal artery
stenosis
•
Frail elderly
•
If adverse effects
Specialist referral
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Step 1
Stop potassium supplement/potassium
sparing diuretics (risk of hyperkalaemia)
Stop NSAID (risk of renal dysfunction)
Stop Lo-Salt
Advise patient about possible hypotension
Start with a low dose ACE inhibitor
Stop ACE inhibitors if creatinine rises
more than 20% or eGFR reduces by
more than 15%. Patient to be referred
for investigation
Step 2
Check urea, creatinine, potassium at 1
week
Check for adverse effects e.g.
symptomatic hypotension, renal
dysfunction, hyperkalaemia (rise in urea
>12mmol/l, creatinine to >200
micromol/l or potassium to >5.5mmol/l)
•
•
If no adverse effects, aim for target dose
•
Check blood chemistry 1 week after
each increment.
If adverse effects
Guideline 707FM.1
Yes
Titrate to this dose in 2 weekly
increments
Step 3
•
Check urea, creatinine and potassium at
3 and 6 months
•
Check for adverse effects e.g.
symptomatic hypotension, renal
dysfunction, hyperkalaemia and
intolerable cough
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2.3
Beta Blockers
Beta blockers should be initiated after diuretic and with ACE inhibitor up-titration
regardless of whether or not symptoms persist. They should be started at low doses
and initiated under the supervision of a doctor or specialist nurse with experience in
the management of heart failure. If there are problems then beta blockers should be
stopped in favour of ACE inhibitors. Up-titration can be undertaken in primary care,
but needs to be under specialist trained nurse/doctor supervision.
In patients with COPD beta blockers can be considered if they have no reversibility
with bronchodilators and they are monitored closely.
Bisoprolol is the beta blocker of choice. Patients with more severe heart failure may
require longer periods between each dose titration. Aim for the target dose or
highest tolerated dose. Patients who are already on a beta blocker for a concomitant
condition should continue with either their current drug or an alternative licensed for
the treatment of heart failure.
Monitoring
•
•
Prior to initiation clinical status (no peripheral oedema) ECG (no 2nd or 3rd
degree heart block), BP (systolic >90mmHg), HR (>55bpm), U& E, LFT
During titration monitor HR, BP and clinical status (especially body weight),
renal function 1-2 weeks after initiation and 1-2 weeks after dose optimisation
Monitoring is the responsibility of the prescriber undertaking the titration. Routine
monitoring of BP and HR should be undertaken by the GP.
Problem solving
See beta blocker algorithm.
2.4 Spironolactone
Treatment with spironolactone should be considered for patients with NYHA class III
or IV heart failure. If the patient remains moderately to severely symptomatic despite
optimal drug therapy (see above) add spironolactone 12.5mg-50mg once a day.
Stop any potassium supplements or potassium sparing diuretics 2 weeks before
starting spironolactone.
Monitoring
See algorithm. Monitoring is the responsibility of the GP.
2.5
Digoxin
Digoxin should be considered for patients who despite optimal doses of diuretics and
ACE inhibitors continue to have symptomatic severe heart failure and very poor left
ventricular function. It is also recommended in patients with atrial fibrillation and any
degree of heart failure.
Monitoring
• Digoxin levels should be checked 7-10 days following drug initiation or
alteration. Blood samples must be taken 6 hours post dose.
Monitoring is the responsibility of the prescriber.
Guideline 707FM.1
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BETA BLOCKER FLOW CHART
Beta-blockers are well tolerated in heart failure and should be considered for
all patients with LVSD who do not have any contraindications
Contraindications:
• True bronchial reactive asthma and reversible airways disease
• Current beta blocker medication
• Second or third degree heart block
•
•
•
•
•
•
•
•
•
Pre-initiation checks:
Clinically Stable and at dry weight
Heart Rate > 55 bpm, no conduction abnormalities
Systolic BP > 90 mmHg
No Contraindications to β-blockade
Initiate beta-blocker therapy:
Patient education
Start with low dose
Remember some beta-blocker is better than no beta-blocker
Check renal function 1-2 weeks after initiation & 1-2 wks after dose optimisation
Monitor clinical status, HR & BP prior to up-titration
Bisoprolol
Week 1
Week 3
Week 5
Week 7
Week 11
Week 15
1.25mg od
2.5mg od
3.75mg od
5mg od
7.5mg od
10mg od
Titration should be tailored to suit individual needs of patients. Titration schedules may be variable.
Worsening heart failure
• Dyspnoea
• Weight Gain
• Peripheral oedema
Increase diuretic dose for 3
days. Refer to diuretic flow
chart.
If symptoms resolve revert to
lower diuretic dose and
continue with beta –blocker
If symptoms persist, consider
reducing or stopping the betablocker dose temporarily wait
for 4 weeks before attempting
to up titrate or reinitiate betablocker
Guideline 707FM.1
Symptomatic
hypotension
(no peripheral oedema)
•
•
•
•
Consider over diuresis and
reduce diuretic dose.
If symptoms persist seek
advice. Consider reducing or
stopping other hypotensives
drugs of no value in heart
failure
Consider temporarily
reducing the ACE inhibitor
dose.
Reduce or stop the betablocker
Wait 4 weeks before attempting
to up titrate or reinitiate betablocker therapy
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Excessive bradycardia
•
•
•
•
•
•
•
•
Heart rate < 50 beats per
minute seek specialist advice
If symptomatic consider
stopping beta blocker dose
Asymptomatic revert to the
lower beta blocker dose
Consider stopping or reducing
other rate controlling drugs.
Review within 1 week, alert
cardiologist if bradycardia
persists
Heart rate < 45 beats per
minute.
Stop beta blocker and arrange a
12 lead ECG, inform the
cardiologist.
Look for signs of heart block or
sick sinus syndrome.
Maintenance
Continue to aim for
target dose or
continue at
maximum tolerated
dose
Ongoing patient
education.
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SPIRONOLACTONE FLOW CHART
Should be considered for patients NYHA III-IV. Persistent signs of sodium
and water retention, already on loop diuretic/ACE inhibitor and or digoxin
and no contraindications
Stop potassium supplements and potassium sparing diuretics 2 weeks
before starting spironolactone. Substitute with a potassium losing
diuretic, for example furosemide.
•
•
•
Check blood chemistry:
eGFR >60ml/min per 1.73m²
Urea <12mmol/L
Potassium <4.5mmol
Commence spironolactone at 12.5mg-25mg once daily
Blood chemistry should be checked initially at:
1week
2 weeks
4 weeks
then
4 weekly for 3 months
3 monthly for 1 year
then
6 monthly thereafter
If potassium rises to 5.5 or eGFR falls below 60ml/min per 1.73m² consider
halving the dose and seek cardiologist advice via telephone. Monitor blood
chemistry closely.
Stop spironolactone and consult a cardiologist if :
• potassium rises ≥5.5mmol/L
• eGFR <30ml/min per 1.73m²
•
•
•
•
Guideline 707FM.1
AND/OR patient develops
Diarrhoea
Vomiting
Or any other cause of sodium and water depletion
Painful gynaecomastia (consider switch to eplerenone - initially
25 mg once daily, increased within 4 weeks to 50 mg once daily.
Note this is an unlicensed indication)
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3.
Monitoring
For monitoring during titration of medication see above.
For routine monitoring patients with stable heart failure should be monitored every 6
months. Patients with unstable heart failure or significant co-morbidities should be
monitored more often, the frequency will be dependant on the status of the individual
patient. Monitoring requirements should include the following:
• Assessment of concordance with lifestyle advice
• Clinical assessment including BP, HR, fluid status, weight
• Biochemistry – urea, creatinine/GFR and electrolytes
• Review of medication
4.
Referral
4.1
Heart Failure Community Matron Service
Patients who fulfil the following criteria may be referred to the Heart Failure Community
Matron Service. Referral forms must be completed in full and faxed to the team
administrator 01296 319515.
Inclusion Criteria
To be admitted to the Community Matron Heart Failure Service all patients must have:
• LVSD confirmed by echo and or other cardiac image modality AND any of the
following:
• Been admitted to hospital within the last 12 months with a primary diagnosis of
heart failure and/or worsening symptom control OR
• Is at high risk of an unplanned hospital admission for this condition
• Needs specialist treatment in community, eg, beta blockers
Exclusion Criteria
Patients will only be excluded if there is one or more of the following evident:
• Unwilling to have support of the community matron.
• Are registered with a GP outside Buckinghamshire PCT.
• Have a history of abusive behaviour/violence towards health care
professionals.
• Are severely cognitively impaired and are without a relative/carer who can
competently manage their care at home.
If the patient does not strictly meet the inclusion criteria, but may benefit from the
intervention, their recruitment to the service will be assessed on an individual basis.
4.2
Cardiology
Referral criteria
•
•
•
•
•
•
Unknown aetiology
For consideration of revascularisation
Progressively increasing diuretic requirement
Increasing creatinine in the absence of medication changes
For initialisation of beta blocker therapy
Continued patient deterioration
Guideline 707FM.1
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PALLIATIVE CARE PROVISION FOR END STAGE HEART FAILURE PATIENTS
The Services Available
The Palliative Care Services across Bucks comprise:
•
•
•
•
•
•
An inpatient palliative care unit with 11 beds, Florence Nightingale House
(FNH), on site of Stoke Mandeville Hospital (SMH).
Inpatient palliative care beds are also accessed at Sue Ryder Hospice,
Nettlebed, St Francis Hospice in Berkhamsted and Thames Valley Hospice,
Windsor.
Hospital palliative care advisory teams at SMH and Wycombe Hospital;
Palliative care outpatient clinics on both sites
Community palliative care nursing teams (Macmillan and Iain Rennie Hospice
at Home) in mid and south Bucks
An independent Day Hospice in South Bucks, and a Day Hospice as part of
FNH
There are two Consultants in Palliative Medicine in post across mid and south
Bucks, supporting the hospital and community palliative care services.
The aims of Palliative Care
The main aim of the supportive and specialist palliative care services is to offer a
timely and holistic review, in order to support patients and enable them to stay at
home. Input from specialist palliative care services may be needed, at different stages
of a patient’s illness, to maintain physical and psychological well-being.
The role of Palliative Care Service:
The services work alongside the primary and secondary health care teams to offer:
•
•
•
•
•
•
•
Advice on/management of symptoms
Emotional and psychological support for the patient and their family/carer
Financial review of eligibility for benefits/grants
Supportive care, including access to complementary therapies/day
care/Inpatient admissions for respite
Co-ordination of place of care, and place of death
Education of healthcare professionals especially regarding the principles of
palliative care; end of life issues; breaking bad news and basic symptom
control
Provision of care in the terminal phase
Criteria for referral to palliative care:
Referrals to the service are accepted for any patients diagnosed with progressive and
advanced disease with a limited prognosis. For heart failure patients, this suggests a
diagnosis of Stage IV of the NYHA classification with any of the specialist palliative
care needs quoted above.
Guideline 707FM.1
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LIMITATIONS TO THE ROLE OF PALLIATIVE CARE IN HEART FAILURE
•
The medical and nursing palliative care teams recognise that their experience
in managing diagnoses other than cancer may be limited.
•
The issue of capacity, both for community services and inpatient units also
needs to be highlighted, especially as heart failure patients may have a longer
prognosis than patients with oncological diagnoses, respite beds are already
limited, and heart failure has a high prevalence.
The palliative care services will work closely alongside their colleagues in
cardiology. It is expected that the cardiology and palliative care teams will offer
mutual educational and clinical support.
End of Life care and other initiatives
•
The palliative care team in mid Bucks (including the medical consultant) meet
regularly with the two Community Matrons in Heart Failure. This is a forum to
discuss patient management, a point of contact for referrals to palliative care,
and an opportunity for education and support for the healthcare staff.
•
The Day Hospice at FNH is considering a programme for patients with heart
failure to teach coping strategies and offer support and advice.
•
The Liverpool Care Pathway (LCP) has been piloted at Stoke Mandeville
Hospital and will be rolled out across the whole Trust in the near future.
Florence Nightingale House hospice already uses the LCP.
•
A Gold Standards Framework co-ordinator is in post across mid and south
Buckinghamshire and GP surgeries are being actively recruited to the
programme.
Summary
The principles of palliative care are transferable to the care of end stage heart failure
patients. Whilst we recognise that there may be some limitations to the provision of
palliative care services for these patients, some of these can be overcome with close
working practices. The medical and nursing palliative care teams are committed to
providing a high quality service accessible to all patients with life threatening illnesses.
2.1
Rationale for main recommendations
This proposal aims for the development of an evidence-based enhanced Heart
Failure service, based on existing resources currently available across the
county, in a manner which will provide equity of service to all patients living
within Buckinghamshire.
2.2
Statement of clinical evidence
Chronic Heart Failure: Full Guideline. NICE 9 October 2003
Guidelines for the diagnosis and treatment of Chronic Heart Failure: Task
Force Report; Eur Heart J, vol 22, issue 17, September 2001
Guideline 707FM.1
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2.4
Contributors and peer review
Dr N Reidy, GP
Dr S Stamp, GP
Dr S Watteeux, GP
Dr P Clifford, Consultant Cardiologist
Dr P Ramrakha, Consultant Cardiologist
Debbie Nicholls, Heart Failure Specialist Nurse
Jacinta Godden, Heart Failure Specialist Nurse
Jo McEwan, Heart Failure Specialist Nurse
Jane Butterworth, PCT Prescribing Advisor
3.
IMPLEMENTATION AND MONITORING
3.1
Implementation of the guideline
• The guidelines will be disseminated in the GP Collaboratives via the
Collaborative Chairs.
• The guidelines will be on the intranet as part of a package of clinical
guidelines for cardiology.
• They will be sent to the Referral Support Centre for reference.
• Use of guidelines will be promoted through practice bulletins; fliers from the
workstream and possibly booklets – depending on external funding being
available.
• Consultant cardiologists will speak at open events for primary care clinicians
to promote the package of guidelines.
3.2
Audit and monitoring
Audit and monitoring is part of the Service Specification for the Heart Failure
Nursing Service.
3.3
Distribution list/dissemination method
Person responsible for implementation and dissemination – primary care
commissioner in workstream
•
•
•
•
Intranet available to all GPs
Hard copies to all GPs plus spares in each practice for locums
Referral Support Centre
Cardiology Dept at Acute Trusts
4.
CONTACTS AND REFERENCES
4.1
Contact list
Dr N Reidy, GP, Workstream Lead, Desborough Surgery, High Wycombe, tel
01494 526006
Debbie Nicholls, Heart Failure Specialist Nurse, email
[email protected]
Jacinta Godden, Heart Failure Specialist Nurse, email
[email protected]
Jo McEwan, Heart Failure Specialist Nurse, email [email protected]
Jane Butterworth, Prescribing Advisor, Bucks PCT, 01494 552200
Dr P Clifford, Consultant Cardiologist, Bucks Hospitals Trust, 01494-526161
Dr S Stamp, GP, Wellington House Surgery, Princes Risborough, 01844
344281
Guideline 707FM.1
17 of 18
Uncontrolled if printed
4.3
References
Chronic Heart Failure: Full Guideline. NICE 9 October 2003
Guidelines for the diagnosis and treatment of Chronic Heart Failure: Task
Force Report; Eur Heart J, vol 22, issue 17, September 2001
Guideline 707FM.1
18 of 18
Uncontrolled if printed

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