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CARDIAC CARE

Heart failure is a common progressive life-limiting condition that can have

a major effect on the quality of life of affected patients and their families. Heart failure occurs when a person’s heart is unable to pump sufficient blood around the body and is most commonly due to the heart muscle being damaged because of a heart attack, or as a result of certain conditions such as high blood pressure or cardiomyopathy (a disease of the heart muscle).

Delivering intravenous diuretics in the community

It is estimated that around half a million people in the UK are living with heart failure with many more undiagnosed cases (Health and Social Care Information Centre [HSCIC], 2015).

This number is expected to rise due to the combined effect of medical advances in the treatment of heart disease and the ageing population.

Heart failure is also a significant burden to healthcare systems, accounting for up to 2% of the UK NHS budget (70% of these costs are due to hospitalisation) and resulting in over one million patient bed days per year (National Institute for Health and Care Excellence [NICE], 2010).

The mean length of hospital stay for a heart failure admission is 12 days (British Society for Heart Failure, 2014).

HEART FAILURE

Symptoms vary depending on the severity of the condition, but people with heart failure often report feeling breathless and tired. In the early stages, fluid retention can be

Lynda Blue, Healthcare Innovation Programme manager, British Heart Foundation

Heart failure is a common chronic condition and people living with it can have periods of relative stability as well as episodes where their symptoms worsen and they require hospital admission and treatment (Chun et al, 2012), such as intravenous (IV) diuretics. Traditionally, patients who failed to respond to an increase in oral diuretics have been admitted to hospital for IV diuretics. The British Heart Foundation (BHF) funded a two-year project in 10 NHS organisations across the UK to determine if delivering IV diuretics in the patient’s home or in a community

by patients and carers (BHF, 2014).The programme was led by heart failure specialist nurses working within existing community heart failure teams and was built on existing evidence that, when compared to other heart failure patients, heart failure patients

times less likely to be hospitalised (BHF, 2008). As IV diuretic services become embedded into existing services, community nurses have an important role to play in working in partnership with heart failure specialist nurses to support patients having

challenges of delivering IV diuretics in the home.

KEYWORDS:Heart failure Intravenous diuretics Life-limiting conditions

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THE SCIENCE — WHAT IS HEART FAILURE?

Heart failure develops when the heart becomes too weak to pump

enough blood around the body at the right pressure. This usually occurs because the muscles of the heart have become too weak or stiff. Heart failure is not the same as a heart attack — rather it means the heart needs support to continue functioning, usually in the form of medicines. Symptoms include shortness of breath, tiredness and swelling of the ankles and can develop quickly (acute heart failure), or over a longer period of time (chronic heart failure).

There are three main types of heart failure:

Left ventricular systolic dysfunction (LVSD): a weakened left ventricle Heart failure with preserved ejection fraction (HFPEF): usually a result of the left ventricle becoming stiff, making it difficult for the chamber to fill with bloodHeart failure caused by diseased or damaged valves.

Source: www.nhs.uk

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controlled with oral diuretics, which help the excess fluid pass out of the body in the form of urine. As the disease progresses, oral diuretics are not always effective enough and patients may require intravenous (IV) administration.

Absorption of oral medications is reliant on gastrointestinal mobility, blood flow, drug formulation and the actions of other medications (Rang et al, 2007). IV drugs are administered directly into the blood stream, bypassing the potential barriers to absorption in oral administration and increasing the medication’s bioavailability (Quin and Read, 2014).

This treatment has traditionally been delivered in hospital and this will continue to be appropriate for many patients with acute decompensated heart failure (a worsening of the symptoms, typically shortness of breath [dyspnoea], oedema and fatigue, in a patient with existing heart disease) (Allen and O’Connor, 2007).

However, for some patients whose condition has advanced, or those at end of life, there are many benefits to home IV therapy demonstrated by the British Heart Foundation [BHF] IV diuretic pilot project (BHF, 2014) (Table 1).

NEW SERVICE MODEL

Of the ten UK-wide NHS organisations that took part in the

given via an infusion pump over periods of up to one hour. The dose depended on individual patient’s needs — usually related to a starting dose comparable to the oral dose of diuretic they were currently taking — and was increased depending on the patient’s response to the initial IV diuretic dose.

The clinical responsibility remained with the heart failure specialist nurses. The cardiologists were only consulted to discuss any variances and complexities not covered by the guidance document and local protocols, and patients did not have to be seen by a nominated cardiologist before starting IV diuretic treatment at home.

All treatment changes and decisions were communicated to the GPs by the heart failure specialist nurses and while little input was required from the GPs, they were supportive.

According to anecdotal reports from the external evaluation team during patient and heart failure specialist nurse interviews, both nurses and patients valued the extra time the home service gave them to discuss the treatment and the patients’ condition. Further information on the project and key learning points are available as BHF resources (BHF, 2015a,b). ChallengesA major challenge was developing the service against a backdrop of NHS reform. Training and maintaining staff cannulation competence were also issues that arose in the set-up phase where patient numbers were initially small.

Solutions included nurses spending time on wards or with paramedic teams to gain experience in inserting cannulas, while one site opted to use butterfly needles (specially designed devices for venipuncture, i.e for accessing a superficial vein for either IV injection or phlebotomy).

Having back-up support from other members of the heart failure nursing team who were also able to

project, the heart failure specialist nurses led the development, management and coordination of the IV diuretic service. This provided an opportunity to redesign existing heart failure services and enhance partnerships with other services.

A steering group, led by the BHF and an expert external panel, developed a guidance document to help the various sites set up the service. Similar steering groups were also formed at the pilot sites to tailor the new way of working to local needs.

Training on cannula insertion was a key learning development for the nurses; while patients were provided with a care record that included all the necessary documentation about their treatment and advice on who to contact and when.

Although the majority of the interventions were performed by the heart failure specialist nurses during the pilot, various models of delivery were used depending on the local infrastructure, including delivery by district nurses, community teams, rapid-response teams and hospital-at-home teams, etc. This showed the potential for district nurses, rapid response teams or community teams to deliver the intervention, with supervision from heart failure specialist nurses.

The decision to deliver IV diuretic therapy was taken by the healthcare professionals involved in the patient’s management if: The patient was receiving optimal

heart failure therapy Increased prescribed doses of

oral loop diuretics and/or added metolazone or thiazides (diuretic medications) had been tried following discussion with their local cardiologist.

Where these measures were insufficient to improve fluid retention, patients were offered the option of community-based IV diuretics, which were administered once or twice daily as a bolus dose, usually via a peripheral line. Doses were usually ‘stepped’, and ranged from 40–250mg (for furosemide). Higher doses were

Table 1: Benefits of delivering IV diuretics in the home

Reduces hospital admissions and the associated distress to the patient and family

Supports early discharge to continue treatment at home

Delivers care ‘closer to home’ in a timely manner

Provides a better experience for patients and carers

Improves patients’ wider care planning and support

Educates patients and carers about heart failure

Enhances patient self-management Empowers patients and carers to manage the

condition more effectively Enables patients to choose to remain at

home at end of life

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challenges faced were:Cannula insertion: this generally only required the heart failure specialist nurses to re-site the cannula and resume treatmentRenal dysfunction: the renal function of all patients was monitored on a daily basis during their IV diuretic treatmentsHealthcare associated infections (HAI): there were no incidences of healthcare associated infections attributable to the IV diuretic treatment.

Clinical-effectivenessOf the patients who underwent this intervention, 79% avoided hospital admission. The majority of the treatments achieved effective target weight loss and/or oedema reduction and/or reduction of patient symptoms.

Cost-effectivenessOnce a service is established, there is potential to generate significant savings in bed days and delivery costs compared with admitting patients to hospital (Figure 1). The start-up costs were relatively modest but essential. The time required to develop and establish the service appeared prohibitive under ‘business-as-usual’ conditions, and therefore required a dedicated start-up resource.

Patient/carer experienceFeedback was consistently positive, with all patients stating that they would opt for home-based treatment again in the future.

Inevitably, a small number of carers found the responsibility of having the patient at home during a complex treatment challenging, but only a small number preferred

deliver IV diuretics in the absence of the heart failure specialist nurse leading the project was important, as was developing on-call systems and working with local out-of-hours services.

Developing local protocols and getting these approved can be time-consuming and attaching protocols to existing nursing or medical guidelines speeds this up. For example, one site added the new IV diuretics protocol to its existing IV antibiotics service guidelines.

As with all IV therapies — including those delivered in hospital — some patients experienced complications such as phlebitis (inflammation of the walls of a vein), but generally any inflammation was only experienced for one day.

Figure 1.Costs of service compared to admitting patients to hospital.

20 cases of cannula problems, only

13 cases of renal dysfunction, nine

10 cases of a phlebitis score of 1 (‘on one or more occasions’), but

of HAI, all

over pilot duration

over the pilot durationAverage cost of delivery

of interventions successfully avoided hospital admission

achieved target reduction in oedema and/or weight

16% did not achieve target reduction but were

Average length of treatment =

preferred home-based

treatment to hospital admission

and of carers

Carers need support to feel

home-based treatment

clinically

*This analysis is based on the heart failure audit data (BHF, 2014) and therefore does not correspond to the cost savings calculated in the IV diuretic final report which preceded the HF audit. It should also be noted that the cost savings based on the pilots are an underestimation as the heart failure specialist nurses were working below full capacity due to a low number of patients.

Table 2: Relevant figures from the two-year evaluation period, across all 10 sites

One-hundred and twenty-six interventions administered to 96 patientsMean age 75Seventy-six percent maleSeventy percent lived with a spouse or other family memberAll but one patient had a wide range of co-morbidities (averaging five per patient)Fifty-four patients (56%) had a previous heart failure-related hospital admission in the year before the intervention

EvaluationAn independent external evaluation of the project demonstrated that the administration of IV diuretics in a community setting was safe, clinically and cost-effective, and valued by patients and carers (the findings are shown in more detail in Figure 1).

With the right infrastructure and resources, existing heart failure specialist nursing teams can provide a service that is a viable alternative to hospital admission, enabling patients to have IV diuretics delivered effectively and safely in the comfort of their own home (BHF, 2014). The patient profile of the pilot study is outlined in Table 2.

SafetyOverall, the pilot data indicated good levels of safety. The most common

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hospital admission. Patients and carers reported confidence in the teams providing the intervention, and were particularly satisfied with the information they were given about the service. This helped them understand what would be required of them and who to contact in an emergency. Box 1 highlights the patient and carer perspective.

Patients indicated that they had gained a wide range of personal benefits from staying at home including:

Being more confident in knowing how to manage their condition, when to call for help and who to speak to in an emergencyBeing able to stay with loved onesConvenience and minimal disruption to day-to-day lifeTime to do what they wantedBeing comfortable and relaxed, not stressed.

Carers who indicated that they felt this treatment was better than staying in hospital, reported that the person they cared for:

Had access to home comfortsHad time and the independence to do what they wanted Avoided the trauma associated with hospital stays and admissionCould carry on with family life.

CONCLUSION

Independent evaluation demonstrated that the administration of IV diuretics in a community setting was safe, clinically and cost-effective, and valued by patients and carers. With the right infrastructure and resources, existing heart failure teams can provide a service that enables patients to have IV diuretics delivered safely and effectively in the comfort of their own homes. This is particularly important to patients in

the advanced stages of heart failure, as it enables them to choose whether they want to remain at home at the end of their lives.

Delivering IV diuretics in the community should be part of a flexible and responsive package of heart failure care, rather than a standalone service. Integration with other teams is essential to ensure sustainability. JCN

REFERENCES

Allen LA, O’Connor CM (2007)Management of acute decompensated heart failure. Can Med Assoc J 176(6):797–805

BHF (2008) Heart failure specialist nurse services in England: Executive summary. Available online: www.bhf.org.uk (accessed 24 November, 2015)

BHF (2014) Evaluation of IV Diuretics Pilot for the British Heart Foundation. Available online: www.brightpurpose.co.uk/files/8014/3335/1048/BH0101-00_-_IVD_Final_Report.pdf (accessed 24 November, 2015)

BHF (2015a) Treating heart failure patients in the community with intravenous diuretics. Available online: www.bhf.org.uk (accessed 24 November, 2015)

BHF (2015b) Learning points for successful introduction of IV diuretics in the community setting. Available online: www.bhf.org.uk (accessed 24 November, 2015)

British Society for Heart Failure (2014)National Heart Failure Audit 2013/14. Available online: www.ucl.ac.uk/nicor/audits/heartfailure/documents/annualreports/hfannual13-14.pdf (accessed 24 November, 2015)

Chun S, Tu JV, Wijeysundera HC, Austin PC, Wang X, Levy D, Lee DS (2012) Lifetime analysis of hospitalizations and survival of patients newly admitted with heart

failure. Circ Heart Fail 5(4): 414–21

HSCIC (2015) QOF 2014/15 results. Available online: http://qof.hscic.gov.uk (accessed 21 November, 2015)

NICE (2010) Chronic heart failure: management. Available online: www.nice.org.uk/guidance/cg108 (accessed 24 November, 2015)

Quinn M, Read H (2014) Nurse-led community diuretics for heart failure patients. Br J Comm Nurs 19(1): 31–8

Rang HP, Dale MM, Ritter JM, Flower RJ (2007) Rang and Dale’s Pharmacology. Sixth edition. Churchill Livingstone, Elsevier, Philadelphia

‘I know I’m living on borrowed time, so every day is a bonus. I don’twant to spend time in hospital, I want to be at home with my wife.’ ( )

‘The trauma experienced during his symptoms was considerably reduced being in his own environment…. he was happy to be surrounded by known carers.’ ( )

Box 1: Patient and carer perspectives KEY POINTSHeart failure is a common chronic condition.

Patients can have periods of relative stability as well as episodes where their symptoms worsen and they require hospital admission and treatment such as intravenous (IV) diuretics.

Traditionally, patients who failed to respond to an increase in oral diuretics were admitted to hospital for IV diuretics.

The British Heart Foundation (BHF) funded a two-year project in 10 NHS centres to determine if delivering IV diuretics in the patient’s home or in a community setting was safe, clinically and cost-effective and well received by patients and carers.

The programme was led by heart failure specialist nurses working within existing community heart failure teams.

As IV diuretic services become embedded into existing services, community nurses have an important role to play in working in partnership with heart failure specialist nurses to support patients having IV diuretics at home.

This article discusses the benefits and challenges of delivering IV diuretics in patients’ home.