Nurse Prescribing in Heart Failure (Integrated Service) Liz Killeen Community Heart Failure CNS & RNP. Galway PCCC. Introduction. Heart Failure affects more than 120,000 Irish people and is one of the most common reasons for hospital admission in the elderly, often requiring a prolonged stay. The prevalence of Heart failure is increasing placing a growing burden on primary care & hospital services. The community heart failure programme, established in 2009 to promote and develop an integrated approach to delivery of care ensuring that management of every heart failure patient is optimal. Improving management through early diagnosis. Streamlining assessment of new patients. Optimize care for patients with established heart failure. Community Echo & Nurse led Services provided in different health centres in Co Galway Adapt a shared care approach to management with the focus of reducing hospital admissions. 1
Implementation Development of local protocol. Diagnostic and Management algorithms. Establishment of Heart Failure Clinics in GUH and PHB. Community Echo Service provided in different health centres in Co Galway. Community Nurse Led Clinics in Co Galway. Extended role as Nurse prescriber. Galway PCCC. 2
Nurse Prescribing in heart failure. Pharmacological therapy for heart failure patients includes slow up titration of ACE inhibitors and Beta-blockers to max tolerated dose and adjustment of diuretics to achieve and maintain euvolaemia. Goal of therapy to improve symptoms, slow or reverse deterioration in myocardial function and reduce mortality. Local guidelines developed to guide GPs in optimising drug therapy for their heart failure patients. Complex patients, lack of time and resources, fragmented care considered a potential barrier to its successful implementation. 3
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RNP Clinical Reporting Relationship Employed by Galway PCCC. Director of Nursing in GUH regarding professional issues. Cardiologists responsible for the heart failure service regarding clinical issues. Area Manager or designate in Galway PCCC on administrative and management issues. Prescribing site coordinator - Professional Development coordinator for Practice Nurses. 5
Nurse prescribing in the community Provision of Community Nurse Led Clinics at locations convenient to the patient: Domiciliary and Nursing home visits. Comprehensive clinical assessment including haemodynamic status, monitoring of blood chemistry and review of medications and possible side effects. Only prescriptive authority for medications listed on CPA. Regular communication & collaboration with GP. Regular audit of prescriptive practice. Methods of Communication On referral. Patient file complied, with relevant history, management plan and echo reports. On each visit nurse led clinical assessment form completed. 1 st copy to GP, 2 nd copy to hospital based CNS & 3 rd copy retained in patients file. Copy of blood results included. If Prescription issued, copy to GP and copy retained in patient file. Information and Communication booklet & living well with heart failure booklet. 6
Prescriptions issued. Prescriptions 2012 9 34 ACE Inhibitors/ARB's Diuretics 26 Beta Blockers 7
Benefits to the patient. Optimisation of evidence based pharmacological therapy in the community. Improve self care management including: Adherence to medication, diet, and exercise. Involve family members/carers. Telemonitoring for patient/carer in maintaining self care/ seeking assistance when symptoms occur. Barriers to self management can be identified and strategies implemented to over come them. Benefits to the patient cont. Facilitate rapid assessment by specialist in event of decompensation. Patient can attend a nurse led clinic locally. Reduce the number of Out patient visits. Provide educational material to enhance self management. Facilitate referral to PCTs. 8
Challenges to prescribing Heart Failure pts in the Community Large geographical area. Timely intervention Working in isolation. Transport of laboratory specimens. Adapting to change. Care often fragmented, different teams looking after patients with significant co morbidities. Predominantly elderly population. Case study. JJ 70 yrs old. Background history. Untreated hypertension. No other prior medical history. Referred to Cardiology April 2012 with increasing SOB x 2Weeks. Commenced on Frusemide 20mg daily by GP. May 2012: Seen in Cardiology OPD. BP 185/80, ECG: Sinus rhythm with frequent PVC s. Echo: Dilated Left Ventricle, Ejection Fraction: 20%. Coronary Angiogram: Normal coronary arteries. Diagnosis: Idiopathic Dilated Cardiomyopathy. Commenced on Ramipril 1.25mgs and Bisoprolol 1.25mgs. Referred to Community CNS. 9
Case Study Continued. June 2012, Attended community nurse led clinic every 2 to 4 weeks. Monitoring of symptoms, electrolytes, creatinine and blood pressure. BB and ACE inhibitor up titrated slowly until max tolerated dose achieved. November 2012: Repeat Echo up to 45-50% Present medications: Aspirin 75mgs/od. Ramipril 10mgs/od. Bisoprolol 10mgs/od. Frusemide 40mgs/od. Lipitor 40mgs/od. Patient discharged back to GP with annual follow up at Cardiology OPD. Conclusion Nurse prescribing in heart failure provides the patient with a more holistic and time efficient service that promotes positive outcomes for patients. 10