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The role of nurses in managing patients with heart failure

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VOL: 101, ISSUE: 09, PAGE NO: 36

Cas Shotter, MSc, RGN, PGDip, DipM, specialist cardiology nurse, West Middlesex University Hospital NHS Trust, Isleworth

An integrated care pathway (ICP) can assist health care professionals to deliver evidenced-based care within a structured framework. Developing a service that incorporates the nurse in managing patients with heart failure is essential because:

- Chronic heart failure has a poor prognosis; at 12 months mortality is 40 per cent;

- It is experienced by 1-2 per cent of the population (National Institute for Clinical Excellence, 2003). However, an ageing population and more effective treatments for heart attack mean that heart failure is increasing;

- It is disabling, with symptoms that have a large impact on quality of life (Cowie et al, 2000).

An ICP also helps health care professionals meet the standards set out by the NSF for CHD.

A systematic approach to care means that both primary and secondary care can agree, implement and audit detailed plans and protocols for treating and following up patients with heart failure.

Implementing an ICP

As a specialist nurse who has run a heart failure clinic, I have found that using clearly defined protocols and a pathway very beneficial. I have had huge encouragement from the medical team, consultants and senior registrars who embraced the new ICP and were willing to support me during clinics. This new venture, although daunting at first, has become a superb tool for nurses as it provides clear guidelines and a treatment framework for managing patients with heart failure (Box 1). This ensures consistency across the service.

Before the development of the ICP for heart failure at West Middlesex Hospital, there was no clear framework and therefore no coordinated approach to delivering care for this group of patients. Teams were not working as efficiently as they could have been and nursing care had become fragmented across the service, resulting in increased lengths of stay for patients. In addition, a champion to drive forward improvements for the service had not been identified. However, the introduction of NICE guidelines and the NSF meant that there was a workable structure in sight.

There were a number of reasons that the trust took the decision to introduce an ICP into its heart failure service. These included the need to:

- Address the targets of the NSF;

- Improve the quality of care/outcomes for patients;

- Promote closer working relationships (both within the trust and with our primary care partners);

- Promote best practice within the trust;

- Decrease variation in care;

- Manage clinical governance and risk.

Challenges of implementation

The implementation of an ICP can be fraught with difficulty and often involves tireless and close monitoring of both medical and nursing staff. The investment is well worth it and using an evidence-based approach can make this challenge much easier.

It is vital the ICP clinical lead makes a conscious effort to listen to the views of staff when developing the pathway and acknowledges their enthusiasm and determination to make the ICP work - without the clinical team on board, the whole process will collapse. Change is always difficult and asking people to work in different ways can cause disharmony. This can, in turn, cause the team to fragment and members to isolate themselves from each other. Reaching agreement about a recommended approach is often a tortuous process, which can stretch even the most patient clinician. However, when a solution has been agreed, it is immensely rewarding.

Two medical consultants (cardiology and care of the elderly) were involved in the development of the heart failure pathway. Their continued support is invaluable in ensuring the pathway is used and developed effectively.

Integrated care pathways in practice

Within the coronary care setting at West Middlesex Hospital, the nurses are fully equipped to care for patients with heart failure and are already very familiar with cardiology-based ICPs. Post myocardial infarction/heart failure patients are identified by the cardiology team and are promptly referred to the heart failure service using the referral form within the ICP. These patients are cared for by the heart failure team either in the acute critical setting or care of the elderly wards.

The heart failure sister uses the ICP when she sees patients in her titration clinic. Self-management strategies and education, medication review and counselling are all essential components of the clinic follow-up.

To complement the services of the heart failure team, the trust is in the process of developing link nurses (nurses with an interest in heart failure on the wards), who will work closely with the heart failure sister and share their knowledge with their colleagues to improve outcomes for patients.

Evidence-based framework

It is essential that staff feel able and equipped to work from an evidence-based framework that enables them to assist a satisfactory treatment plan. The training and teaching of the staff in the management of the pathway are paramount to its success.

Pathways suitable in critical care can be adapted for use elsewhere, for example in acute assessment and care of older people. In addition, they enable nursing/medical staff to maximise patient outcomes as they become more familiar with their patients’ treatment.

The ICP can greatly help during the acute phase of treatment as it recommends a common treatment plan for heart failure patients, which all staff can follow. However, an element of flexibility is built into the ICP so adjustments can be made to suit individual patient needs.

Multidisciplinary working

Within primary and secondary care, it is essential that staff work as a team, regardless of organisational boundaries. Those working in primary care will need to have access to a system that identifies patients requiring heart failure services. The ICP at West Middlesex Hospital has been shared with the local primary care trust so that this process can be managed appropriately. So, for example, the referral form from the ICP has been adapted to suit the needs of GPs to make it easier for them to refer the appropriate patients.

Where to start the pathway is under some debate. The pathway is accessible in all the relevant clinical areas, although it is felt that A&E would not be the most appropriate area as the diagnosis may be provisional. The proposed route is that once the patient has been admitted and an assessment has been made using the ICP by the consultant, heart failure sister and the team, it can be used in the clinical area and then followed through to the outpatient clinic.

The use of protocols in this field is difficult. The needs of primary and secondary care are different although health care staff are all working towards a common goal. Essentially, they want patients to have the best possible care and wish to work towards the guidelines that have been set out to assist them. When staff work together with integrated pathways, they can greatly improve services to patients.

Critical success factors

The successful implementation of an ICP is dependent on the following factors:

- Identifying and addressing bottlenecks in the service through process mapping;

- Focusing on demand and capacity - not activity;

- Sharing knowledge about the ICP across the entire organisation;

- Developing a structured training plan to include all care pathways, which will then act as a reference guide;

- Keeping the momentum going - a challenging but essential requirement;

- Sharing ideas and developments with other health care professionals;

- Building in flexibility so that the pathway can be adapted and changed according to patient needs. Audit and discovery interviews with patients are a key part of this process.

Future vision of care pathways

ICPs will become electronic as part of the integrated care record service implementation (to be introduced in 2008), which will facilitate the sharing of information electronically. Decision-making in primary care will be improved and referrals and automatic care summaries will be generated. An accurate real-time record of care will be provided.

One of the main challenges health care professionals face is constantly finding ways of engaging patients in their care. It is my vision that patients will have a hand-held record of their treatment from their acute phase to the diagnostic/titration phase and out into primary care should they wish.

This will require sensitive management and training. It is anticipated that patients will inform us of what is most important to them so this can be incorporated into the care pathway.

- This article has been double-blind peer-reviewed.

For related articles on this subject and links to relevant websites see

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