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Audit praises rise in heart failure patients seeing specialist nurses on general wards

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There has been an “important” increase in the percentage of heart failure patients seeing a specialist nurse after being admitted to a general medical ward, according to an independent audit.

It highlighted that that only just under half of patients were admitted to cardiology wards, where survival rates were better, which continued a trend seen in three previous reviews.

“Specialist care in hospital matters. There is still much to do”

Theresa McDonagh

However, it highlighted that heart failure nurses saw 33% of patients who were admitted onto general medical wards in England and Wales during 2016, up from 24% the year before.

“This is important as specialist care improves mortality,” said the ninth National Heart Failure Audit Annual Report, published today.

In addition, the report noted that 57% of those discharged had received follow-up from a heart failure specialist nurse.

Again, it highlighted that mortality at one year of follow-up was lower for those seen by heart failure nurses or receiving cardiology follow-up.

The report said the “consistent message” that arose from the audit was that outcomes for those admitted to hospital were better for those with access to specialist heart failure care.

“We need to continue our efforts to treat more of these patients on cardiology wards, make sure that those admitted to general medical wards are seen by heart failure specialists (both nurses and doctors) during the admission, so that they have optimum access to appropriate diagnostic tests, receive the correct disease-modifying treatments during the admission and have robust specialist follow-up in place at discharge,” it stated.

“We recognise that there is scope for even more improvement”

Bruce Keogh

The latest heart failure audit, commissioned by the Health Quality Improvement Partnership, included data from 137 trusts in England and six health boards in Wales.

The audit, which monitors the treatment and care of people with an unscheduled admission to hospital who are discharged with a primary diagnosis of heart failure, was the largest to date.

It covered 66,695 acute admissions in England and Wales between April 2015 and March 2016, representing 82% of heart failure admissions as the primary diagnosis in England and 77% in Wales.

The report was drawn up by a steering group of 14 clinicians and managers – including Dawn Lambert, heart failure nurse specialist at Portsmouth Hospitals NHS Trust, and Kathy Simmonds, heart failure nurse specialist at Kettering General Hospital NHS Foundation Trust.

Overall, the report found that more patients than ever surviving heart failure following vital improvements, as more people received key tests and prescriptions, and saw specialist staff.

The mortality of patients hospitalised with heart failure was significantly lower in 2015-16 at 8.9%, compared to 9.6% in 2014-15, it said.

“It is imperative we continue to close variations in heart failure care across hospitals”

Nilesh Samani

The prescription of key disease-modifying drugs (DMDs) for patients with heart failure and a reduced left ventricular ejection fraction (HF-REF) increased. Life-saving and inexpensive beta- blockers were prescribed to 87% of patients and mineralocorticoid antagonists to 53%.

Prescription rates for all three key DMDs – angiotensin converting enzyme inhibitors, beta-blockers and mineralocorticoid antagonists – for those with HF-REF have increased from 35% to 53% for those admitted to cardiology wards over the last six years.

Irrespective of the place of admission, 47% of patients with HF-REF seen by a member of the specialist heart failure team as an inpatient, were prescribed all three drugs, up from 45% in 2014-15 – albeit with “considerable room” for further improvement, noted the report.

During hospital admission, more than 90% of patients received an echocardiogram. But rates were higher for those admitted to cardiology (96%) than general medical (85%) wards.

The number of patients seen by heart failure specialists remained high at 80% in 2015-16 and it noted, in particular, that heart failure nurses saw more patients admitted onto general medical wards than in 2014-15.

Yet while the audit found several improvements, it said mortality remained high and quality of care varied from one hospital to another, and within a hospital, between the specialist and other wards.

“We need to make sure that those admitted to general medical wards are seen by heart failure specialists (both nurses and doctors) during the admission”

Audit report

It called for more patients to be admitted to cardiology wards, as well as more comprehensive prescription and dose optimisation in order to prevent numerous additional deaths.

For example, it said that if patients identified as having HF-REF, who left hospital on none of the three DMDs, had received all three, then upwards of an additional 212 patients would likely have still been alive.

The audit’s clinical lead Professor Theresa McDonagh, clinical lead for cardiology and heart failure at King’s College Hospital, London, said: “These results from our national audit, are encouraging but leave room for further improvement.

“For the first time we have seen a small improvement in mortality in hospital, at 30 days and at one year,” she said. “Hopefully we are now beginning to see the effects of better management of heart failure in hospital.

She added: “We know how to diagnose it, investigate it and – for the majority of patients with reduced ejection fraction – we have effective treatments.

“Specialist care in hospital matters,” she said. “Getting onto the correct drugs matters and co-ordinated specialist care post discharge matters. There is still much to do.”

Sir Bruce Keogh, national medical director at NHS England, said: “This independent study shows that improvements to NHS heart failure services have had a significant positive impact for people suffering this devastating condition.

Sir_Bruce_Keogh_NHS_England_medical_director

Sir_Bruce_Keogh_NHS_England_medical_director

Bruce Keogh

“Increasing numbers of patients are getting specialist help and the full range of treatments thanks to years of world-leading scientific and clinical research and the efforts of NHS staff,” he said.

He added: “We recognise that there is scope for even more improvement but the progress highlighted today will be a spur for us to do even more to improve care and survival rates.”

Responding to the report, Professor Sir Nilesh Samani, medical director of the British Heart Foundation, said: “Heart failure blights the lives of more than half a million people across the UK, and in its severest form has a worse prognosis than many cancers.

“However, providing optimal treatment can help patients lead longer, healthier lives,” he said. “This audit shows promising signs that the quality of hospital care for heart failure is improving, with fewer people dying as a result.

“However, we need to build on this progress,” he said. “It is imperative we continue to close variations in heart failure care across hospitals and ensure more patients receive the best possible treatments.”

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