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Reducing hospital readmissions for people with heart failure

Paul Warburton, MSc, RN, Cert Ed.

Heart Failure Nurse Specialist, Countess of Chester Hospital NHS Trust, Chester

Heart failure is an underlying symptom of another disease process. Box 1 presents a definition of heart failure. Almost all forms of heart disease can lead to heart failure and it is important to remember that the term refers to a clinical syndrome rather than a specific diagnosis.

Heart failure is an underlying symptom of another disease process. Box 1 presents a definition of heart failure. Almost all forms of heart disease can lead to heart failure and it is important to remember that the term refers to a clinical syndrome rather than a specific diagnosis.

Heart failure is a growing health problem; this is due to both an ageing population and the increasing number of patients surviving heart attacks left with residual impairment of their heart function.

Heart failure affects approximately 2% of the general population (Cowie et al, 1997) - around 1.4 million people in the UK. The annual incidence is about one new case per 1000 population each year and this figure is rising by about 10% per annum (Department of Health, 2000). This increases with age to more than 10 cases per 1000 population in those aged 85 years and over. There are thus about 150 000 new cases each year in the UK (Cleland et al, 2000). The median age of presentation is 76 and the male-to-female ratio is about two to one (DoH, 2000). The clinical symptoms of heart failure are listed in Box 2.

In the UK heart failure is the most common cause of medical admissions to hospital in people over the age of 65 years (Hobbs, 1999). Preventable reasons for readmission to hospital are listed in Box 3. In contrast to coronary artery disease and stroke, the number of admissions to hospital and deaths due to heart failure is increasing and is predicted to rise further (Morgan et al, 1999). Annual mortality ranges from 10 to 50%, dependent upon the severity (Consensus, 1987; Hobbs, 1999) and the prognosis is at least as bad as many forms of cancer. Less than 50% of patients are still alive five years after diagnosis (Dahleen and Roberts, 1995; Hobbs, 1999). Not only is heart failure deadly, it is also associated with an extremely poor quality of life (Stewart et al, 1989).

Estimates of the cost of heart failure to the NHS health-care budget range from 1 to 4% and approximately 60% of this is from hospitalisations. In 1991, £360 million was spent on heart failure in the UK (Murray et al, 1993); this figure is now probably in excess of £1.4 billion (Stewart et al, 2001). In view of the increasing incidence of heart failure in the population the expenditure on heart failure is likely to rise in the future. Early and frequent readmission to hospital is common in heart failure, particularly with elderly patients. Rates of readmission range from 27 to 47% within three to six months of initial discharge (Michalsen et al, 1998). Hospital admission is often prolonged: in 1990 the mean length of stay for a heart failure admission was 11.4 days in an acute medical ward and 28.5 days in an acute care-of-the-elderly ward (McMurray et al, 1993).

Management of heart failure in the community
The majority of people with heart failure are managed in the community by the primary care team and only a minority are admitted or readmitted to hospital each year. UK studies suggest that, in the early 1990s, 0.2% of the population were admitted to hospital with heart failure each year. This accounted for more than 5% of all adult general medical and care-of-the-elderly admissions to hospital (McMurray et al, 1993). Many admissions are predictable and therefore, with timely and correct intervention, preventable.

Evidence suggests that the diagnosis and treatment of people with heart failure remains a problem; a high proportion of people with the condition are undiagnosed and of those who are diagnosed many are under-treated (McMurray, 1998). To manage patients with heart failure successfully and reduce the risk of admission and readmission to hospital, a systematic, multidisciplinary approach should be adopted across primary and secondary care. This approach should include locally developed and agreed guidelines for the diagnosis and management of patients with heart failure.

Diagnosis of heart failure has been described previously (Riley and Blue, 2001) and is made on the basis of several investigations (Box 4).

Once a diagnosis of heart failure has been confirmed in primary or secondary care, all patients should have access to education regarding their condition (Box 5), ongoing long-term support and regular review. The National Service Framework for Coronary Heart Disease suggests that all people with heart failure should have a full and appropriate package of advice and interventions and should be offered a regular review as part of a systematic approach to their management.

The management of heart failure
Approaches to the management of heart failure can be both non-pharmacological and pharmacological. In order to prevent admission and readmission to hospital both approaches should be used as each complements the other. A number of nurse-led models of interventions exist. Three examples of positive randomised controlled trials are shown in Table 1. These include a community-based specialist nurse intervention, a nurse/pharmacist post-discharge review and hospital-based nurse-led clinics. Each approach was developed in response to local need and each have their merits.

The common component in each of these models is the nurse intervention and leadership. The effective ingredients are common to those used to manage other chronic conditions such as diabetes and include the provision of comprehensive education regarding the condition.

Patient education
A common problem in the management of people with heart failure is the lack of the use of the term. Patients are therefore uninformed of a condition that will remain with them for life. 'Heart failure' is an unfortunate title that is not immediately understood and requires detailed explanation and reassurance. The term is often not used or inadequately explained by health-care professionals and is replaced with other terms such as a 'weak' or 'damaged' heart that sound less daunting to the patient.

In order for patients to fully understand their condition, comply with their treatment and to be able to report signs and symptoms of deterioration, a patient-centred education programme needs to be delivered to all patients. Verbal information should be reinforced with written information such as the British Heart Foundation information leaflet Living with Heart Failure (BHF, 1999) or a locally developed booklet such as My Heart Book (Greater Glasgow Health Board, 2000).

Successful management of heart failure often involves major changes in lifestyle for patients and their families. A diagnosis of heart failure invariably means a lifetime of taking multiple medications each day. Dietary habits and activities require adjustment and often present difficulties for patients and their families as these changes can conflict with the habits of a lifetime. Weight and any symptoms of heart failure must be monitored each day so that deterioration is identified early and prompt treatment is obtained. This should be through clearly defined routes such as practice nurse, specialist nurse or GP.

Patients must also come to terms with the psychological burden of living with the day-to-day difficulties of heart failure - a reduced quality of life and the knowledge that their life expectancy may be shortened. Formal assessment of an individual's emotional state is often overlooked but it can be invaluable and allow interventions such as referral to psychological support services or palliative care where available.

Summary of aims of treatment
The aims of treatment in heart failure are to:

- Control symptoms

- Improve quality of life

- Slow disease progression.

Comprehensive heart failure management includes:

- Development of an accurate heart failure register

- Patient education following diagnosis of heart failure

- Routine review by the primary care team of heart failure patients discharged from hospital. This will allow an early assessment of a patient's condition and may include a home visit by a district nurse to ascertain the patient's understanding of the condition, assess his or her symptoms, progress, compliance with medications and the need for any further intervention

- Ongoing education, review and support by a specialist nurse as required and ease of access to that service (Cline et al, 1998; Blue et al, 2001)

- Regular practice-based reviews to assess patients (DoH, 2000)

- Access to cardiac rehabilitation (European Heart Failure Training Group, 1998)

- Access to palliative care where indicated (McCarthy et al, 1997).

Conclusion
In order to provide a complete package of effective interventions for people with heart failure, primary and secondary care need to work in collaboration to develop a service that is tailored to meet local needs and demands. Evidence suggests that specialist nurse input has an increasingly important role to play in the successful management of people with heart failure. The role of the specialist nurse is defined in Box 6. Such roles, however, provide one part of what should be a comprehensive, locally developed, multidisciplinary service for the management of all people with this deadly and disabling condition.

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Stewart, S., Blue, L. (2001)Specialist nurse intervention in chronic heart failure: a critical review. In: Stewart, S., Blue, L. Improving Outcomes in Chronic Heart Failure. London: BMJ Books.

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Stewart, S., Vandenbroek, A., Pearson, S., Horowitz, J. (1999)Prolonged beneficial effects of a home-based intervention on unplanned readmissions and mortality among congestive heart failure patients. Archives of Internal Medicine 159: 257-261.

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