Primary Care
Chronic Heart Failure
(Left Ventricular Systolic Dysfunction)
How to Guide
The former Public Health Wales Primary Care Quality Team, now incorporated within the Primary and Community Care Development and Innovation Hub, developed a series of quality improvement toolkits to assist practices in collating and reviewing information. From information received, practices still find these toolkits useful, therefore they will remain on this webpage for your ease of reference. Please note, however, that the date of publication is clearly stated in the toolkit and that the evidence within may have changed since publication
This guide has been produced to enable GP Practices and their teams to successfully implement a series of care bundles in a timely manner and apply the Model for Improvement when monitoring patients with suspected /confirmed Heart Failure.
There is a summarised version of this document which can be accessed at
PCQIS site http://howis.wales.nhs.uk/sitesplus/888/page/34030
Final
December 2012
Acknowledgements
This guide has been produced by Primary Care Quality & Information Service (PCQIS) with input from Dr Paul Myres, Debbie Davies, Dr Graham Thomas, Dr Richard Lawrance, Louise Howard Baker, and Breeda Worthington (NLIAH) and the All Wales Cardiac Network Groups.
We would like to thank Health Boards and GP Practices in Wales and their teams for their endeavours in implementing these interventions and also feeding back lessons and experiences gained.
PCQIS and 1000 Lives Plus have successfully engaged with a number of experts in Primary and Secondary care to produce this guide for Chronic Heart Failure. It has been developed by specialist practitioners in Wales and the content based on evidence and recommendations from NICE1, National Heart Failure Audit 2012 2, European Society of Cardiology (ESC) guidelines for the diagnosis and treatment of acute and chronic heart failure 20123, Cardiac Disease NSF for Wales4, PCQIS chronic heart failure toolkit5, Welsh Medicines Resource Centre 6, European Society of Cardiology (ESC) 2008 Acute and Chronic Heart Failure Clinical Practice Guidelines 7, Prodigy (formerly CKS) Chronic Heart Failure guidelines 2010.8
We wish to thank and acknowledge the Institute for Healthcare Improvement (IHI) and the Health Foundation for their support and contribution to 1000 Lives Plus
Date of publication and Proposed Review Date
This guide was published in December 2012 and will be reviewed in 2014. The latest version will be available online on the programme’s website: www.1000livesplus.wales.nhs.uk
Purpose of the Guide
The aim of this guide is to assist practices to review the quality of the service that they provide to patients with suspected /confirmed Chronic Heart Failure.
It has been produced to enable GP Practices and their teams to successfully implement a series of care bundles in a timely manner, and to improve the safety and quality of care that their patients receive.
This ‘How to Guide’ must be read in conjunction with the following:
· Leading the Way to Safety and Quality Improvement
http://www.wales.nhs.uk/sites3/Documents/781/How%20to%20%281%29%20Leading%20the%20Way%20%28Feb%202011%29%20Web.pdf
· How to Improve
The Quality Improvement Guide
Further information is also available to support you in your improvement work:
PCQIS site http://howis.wales.nhs.uk/sitesplus/888/page/34030
Deanery site
The new GP Appraisal & CPD website can be found here;
https://nhswalesappraisal.org.uk/
1000 Lives Plus 14 Cathedral Road, Cardiff CF11 9LJ | Tel: (029) 2022 7744
Email: | Web: www.1000livesplus.wales.nhs.uk
Twitter: www.twitter.com/1000livesplus
Foreword
All general medical practices will have patients with heart failure. Research has shown what treatments improve quality of life and prolong life. Guidelines have been published to help us deliver those treatments. However, we know that not all eligible patients are receiving those treatments.
This guide, and its associated collaborative programme, aims to put that right by encouraging and supporting primary medical care teams to examine the care they provide, reflect on their services and try different approaches as necessary to improve.
The 1000 lives plus approach requires practices to design their processes to meet the needs of their patients in ways appropriate to their circumstances by considering their own data and comparing it with what they would wish it to be. It encourages practices to compare themselves with others and learn from what others have done. Similarly it asks participating practices to share their learning with others.
This is the first “How to Guide” specifically aimed at general medical practice. It is concerned with an area of disease where we know collectively we can do better. It relies on us to work constructively with our secondary care colleagues. It puts responsibility on all of us in the general medical practice team to improve.
Paul Myres
Primary Medical Care Lead
1000 lives plus
Chair
Royal College of GPs Wales
Making Patient Safety a priority
The 1000 Lives Campaign has shown that by working as a collaboration it encompasses not only health services within secondary care organisations but also community based alliances from health clinics and associated general practices who together support mutual aims: the avoidance of unnecessary harm, improvement to services that are delivered and an evidence-informed approach with patient safety as a priority.
The enthusiasm, energy and commitment of teams to improve patient safety by following a systematic, evidence-based approach has resulted in many examples of demonstrable safety improvement.
However, as we move forward with 1000 Lives Plus, we know that harm and error continue to be a fact of life and that this applies to health systems across the world. We know that much of this harm is avoidable and that we can make changes that reduce the risk of harm occurring. Safety problems can’t be solved by using the same kind of thinking that created them in the first place.
In General Practice the field of patient safety has tended to focus on adverse events and on the development of specific solutions aimed at preventing these events. We know that much of the harm is avoidable and that changes in practice and procedures can reduce the risk of harm occurring. Developing a positive safety culture depends on communication between all members of the health care organisation. The health care organisation needs to:
· Acknowledge the scope of the problem and make a clear commitment to change.
· Recognise that most harm is caused by bad systems and not bad people.
· Acknowledge that improving patient safety and outcomes requires everyone on the health care team to work in partnership with one another, patients and families.
The national vision for NHS Wales is to create a world-class service by 2015; one which minimises avoidable death, pain, delays, helplessness and waste. The guide is grounded in practical experience and builds on learning from organisations across Wales. The National Patient Safety Agency Seven Steps to patient safety in general practice guide describes the key steps for a general practice to take to avoid harming the patients they care for. http://www.nrls.npsa.nhs.uk/resources/collections/seven-steps-to-patient-safety/?entryid45=59804
Contents Page
Introduction 6
Driver Diagram 9
Getting Started 10
Drivers and Interventions 11
How do we introduce changes to processes? 16
How do we measure for Improvement? 19
References 24
Appendices
Setting up your team 25
The Model for Improvement 27
How to test change 28
Process Measures with descriptors 29
READ codes 32
Helpful Resources 38
Glossary 46
Introduction
Aim: To Reduce Morbidity for patients with Chronic Heart Failure (CHF) (Left Ventricular Systolic Dysfunction) (LVSD)
Heart failure is increasing in prevalence as a chronic condition and it presents significant challenges to individuals, their families and the healthcare system.
Currently 900,000 people in the UK have heart failure. The incidence and prevalence of heart failure rises steeply with age, the average age of first diagnosis is 76 years. Heart failure has a poor prognosis, almost 40% of patients diagnosed die within a year.1,2
Prevalence of recorded heart failure mostly falls short of predicted levels which could indicate that there is a largely unseen demand for investigations, clinical assessment and care. There are several types of heart failure2. The strongest evidence base at present is for Left Ventricular Dysfunction (LVSD).
Whilst substantial progress has been made over the last few years, there is considerable national variation8:
· Variation between different groups of patients.
· Variation in the confirmation of a diagnosis.
· Variation in access to evidence-based treatment and heart failure specialist staff.
The impact of delivering evidence-based care
One of the main objectives of managing patients with CHF is to introduce appropriate drug therapy, including ACE inhibitors and beta-blockers, ideally titrating doses up to the optimal target doses used in the large randomised controlled trials. There is good evidence that this goal can be achieved in the majority of patients if a determined and concerted effort is made in hospital, at outpatient clinics and in the community.1
Over 50 clinical trials have shown that, in patients with reduced left ventricular systolic function, ACE inhibitors, angiotensin receptor blockers (ARBs), and beta-blockers reduce symptoms, readmission rates, and mortality. Studies report that the use of ACE inhibitors or ARBs at optimal doses reduces the risk of mortality by 15-25% and anticoagulation for people with heart failure who have atrial fibrillation reduces risk of stroke by 60-70%. When a variety of different pharmacological options are available, positive benefits are achievable if the drugs are provided appropriately and patients are supported to be concordant with their treatment.1,2
The NSF and associated guidelines, underpinned by audit and evaluation, emphasise the need for improved access to diagnostic services (including echocardiography and B-type natriuretic peptide (BNP) testing), and robust clinical management involving non pharmacological and pharmacological treatment, including resynchronisation device therapy, assist devices and transplantation. Once the diagnosis of CHF is confirmed, patients can be started (often sequentially) on appropriate medication and a care pathway with the aim of relieving symptoms, improving health-related quality of life, and reducing morbidity and mortality.1,9
The role of Primary Care in delivering improvement (QOF) 2011/12
There is good evidence that appropriate diagnosis, treatment and management can improve quality of life and help reduce admissions and readmissions, morbidity and mortality2
The General Medical Services Quality and Outcomes Framework (QOF) manages chronic diseases in primary care and incorporated three measures on the diagnosis and management of heart failure. However, there is still wide variation in the number of patients on GP disease registers with suspected heart failure. Local prevalence of recorded heart failure mostly falls short of predicted levels1, which could indicate that there is a largely unseen demand for investigations, clinical assessment and care. The role for Primary Care service is to implement reliable interventions described in this guide and then to focus intensively on managing CHF patients safely.
Data Quality System (DQS) in Wales and Audit+
In November 2007, the Welsh Government’s Primary Care Informatics Programme (now part of NHS Wales Informatics (NWIS) launched the Data Quality System. This was a natural progression from previous initiatives with the aim of providing an efficient, automated and consistent software tool, primarily to support General Medical practices and as a by-product support the bigger picture within Wales.
The DQS comprises of a General Practice based tool, ‘Audit+’ and a secure central NHS Wales-based web repository ‘Audit Web’ which receives scheduled automated aggregate data submissions from Audit+.
Participation in the DQS within Wales is voluntary; Audit+ is provided free to all General Practices in Wales irrespective of their clinical information system and is now deployed in 97% of General Practices. To ensure continued acceptance from practices, reflected in continued high level of participation, the development and implementation of all modules is discussed with GPC (Wales) representatives to guarantee ongoing professional approval. NWIS works closely with Public Health Wales and other key NHS organisations to produce modules within Audit+ including amongst others:
· INR Monitoring
· Minor Surgery
· Learning Disabilities
· Near Patient Testing
· QOF age/sex standardised prevalence
· Flu vaccinations
· Pneumococcal vaccinations
· Communicable diseases
· CHD National Service Framework
· Diabetes National Service Framework / Directed Enhanced Service
As is the case with any software product the results produced are only as good as the source data supplied. Audit+ therefore contains specific searches within other modules to encourage General Practices to improve the data quality within their clinical system that supports their day-to-day activities. Audit+ modules to support cardiovascular risk will also contain such searches to ensure that the data required to undertake risk calculations is as complete as possible.
Registration process
The Audit+ product collects data from all practices who have signed up to its use. The Practice or service provider will be undertaking testing and measurement of ideas using the improvement methodology as part of a collaborative, made up of themselves and other practices or service providers. The precise size and form of the collaborative will be determined over the coming months.
It will be a voluntary subscription to undertake the interventions described in this improvement guide. In order to filter data from the Audit + tool, to feed back to practices who have subscribed to the collaborative(s), the 1000 Lives Plus programme will need to identify who has subscribed to which collaborative (defined by its improvement focus e.g. Chronic Heart Failure). In order to do this, the practice, once signed up to a collaborative, will need to register and accepted that they have agreed to take part in the particular collaborative(s). The registration will take place using the existing “Public Health Wales PCQIS Quality Improvement Tools”, which will be familiar to many GP practices because it hosts the all Wales clinical governance self assessment tool. There will be 1000 Lives Plus collaborative registration form available at this site. Practice Registration Form
Purpose of the Registration Form
The Registration Form will allow practices and other providers to register their subscription to one or more of a number of quality improvement collaboratives covering a range of clinical practice issues, starting with a choice of
· Chronic Heart Failure (Left Ventricular Systolic Dysfunction)