Local Needs Assessment Heart Failure and Cardiac Rehabilitation The Human Burden of Heart Failure Heart failure is a life-limiting condition that people can live with for a number of years and require a considerable amount of medical care. One in every 100 people in the UK suffers the effects of heart failure, increasing to around 7% over the age of 75 years. This number is due to rise as the survival of patients with cardiovascular disease increases alongside an ageing population. In Wales (taking account of possible coding errors) the average number of heart failure readmissions in 30 days for 2009/10 was 10.7%; for ABHB this was 12% in 2012 and there has been little change during the last three years. As evidenced by the latest National Clinical Audit of Heart Failure annual mortality in hospitalised patients remains poor; 30% at one year. For those who have access to specialist heart failure care mortality is significantly better at 23% Patients with heart failure experience a high level of co-morbidity, a poor quality of life and over a third suffer from depression (3). The Financial Burden of Heart Failure Heart failure remains one of the main reasons for admission or readmission in adults aged over 65 years. 2% of the NHS Budget is spent on HF-related care in the UK. The Heart Failure and Cardiac Rehabilitation Service at Led by a Consultant Nurse the Cardiac Rehabilitation (CR) and Heart Failure (HF) services work across ABHB. With multidisciplinary teams based in Newport, Abergavenny, Caerphilly and Pontypool Draft V1.1 Page 1 of 8
the CR service caters for the majority of patients with heart disease. The current exception are patients with heart failure living in the Newport area who, whilst being offered the opportunity of attending other sites eg Pontypool, maybe unable to travel. The other category is people with a primary diagnosis of atrial fibrillation. On completion of CR people are referred to community classes. Unlike other CR services in Wales our service benefits from the expertise of Occupational Therapy/ Fitness instructors working within the MDT and two nurses trained in CBT. The Heart Failure service is aligned to CR and has a HF specialist nurse for each locality (Monmouth/Blaenau Gwent/Newport/ Torfaen and Caerphilly). The heart failure nurses run nurse led clinics (in RGH, NH, YYF, YAB and Monmouth Community Hospital) as well as undertaking home visits. The service originally based on referral criteria of confirmed Left Ventricular Systolic Dysfunction now accepts patients with Heart Failure and a Normal Ejection Fraction this inclusion is impacting on the ability of the service to meet demand. Two projects; the Community Parenteral Diuretic Service for patients with end stage heart failure and the use of an Acute HF Nurse based at RGH to reduce HF admissions and deliver evidence based care over 2 years are currently under way. Compliance to National Audits and patient stories under-pin service improvement work and due to the initiation, participation and publication of research and project findings both services have a national reputation for excellence in the provision of a patient centred care. With the premise of improving patient care the CR teams in the South and North of ABHB are supported by a two respective registered charities. Draft V1.1 Page 2 of 8
Area profile Local Authorities Blaenau Gwent, Caerphilly, Monmouthshire, Newport, Torfaen Size 1,553km² Population of area 561,420 Population per km² 360.9 % LSOA in most deprived 5 th 24 of Wales % population>75yrs 8.3 Specialist Heart Failure Started: 2003; All areas: from 2009 Nurse Service HFSN/ population ratio 1:114,575 WTE posts Permanent posts 1.0 WTE Blaenau Gwent 1.0 WTE Monmouthshire 1.0 WTE Caerphilly 1.0 WTE Torfaen 0.8 WTE Newport 4.8 TOTAL HFSN deficit 0.3 WTE (based on LVSD 1 per 100,000) 4.0 WTE based on LVSD + HFNEF Independent prescribers 3 Re Admission < 30 days 12.5% Current projects to reduce Parenteral Diuretics in the readmissions 2013-2015 Community Nov 2013 6 months initial funding Band 7 1.0 WTE RGH Acute HF Nurse Band 6 0.4WTE 2yrs external funding Number of BHF supported 4 posts Dedicated secretarial support Nurse Consultant Restricted adequate in Torfaen; clinic support and patient letters for one clinic per week Newport; patient letters for Caerphilly (one clinic per week); Monmouth and Blaenau Gwent clinic arrangement support only (two clinics per area) no letter typing. 0.5 WTE Draft V1.1 Page 3 of 8
Average active case load 150 per nurse Waiting list 2-4 weeks to first OPA Hours of operation Flexible within a five day week Service base Monmouthshire and Blaenau Gwent Cardiac Rehab, Nevill Hall Hospital Torfaen Chronic Conditions /Locality Caerphilly Chronic Conditions/Locality Newport Frailty Team/St Woolos Service delivery Apart from Torfaen and Caerphilly the nurses work for the Cardiology Directorate, all link in with respective Cardiologists. Professional management by the Nurse Consultant. Nurse led clinics are provided in community hospitals Monow Vale, County, YAB, YYF and secondary care - Nevill Hall, Royal Gwent. Home visits as required. The nurses covering Blaenau Gwent and Monmouthshire provide dedicated CR and review in-patients at NH Referral criteria All patients with a confirmed diagnosis including HFPEF Referral source Cardiology/ Wards/ GP Additional services/ monitoring routinely available Named Cardiologist Stephen Hutchison and Phillip Campbell B Type Natriuretic Peptide Yes GPwSI No Cardiac rehabilitation Dedicated service - all areas apart from Newport Palliative care St Davids Newport& Monmouthshire, Hospice of the Valleys Blaenau Gwent. Caerphilly Main priority continues to be cancer patients Tele medicine Torfaen for 15 patients National Heart Failure Audit Nevill Hall since 2009, commence RGH June 2012 Draft V1.1 Page 4 of 8
ABM Bridgend ABM NPT ABM West C&V RCT North RCT South PTHB ABHB Blaenau/Mon ABHB Torfaen ABHB Newport ABHB Caerphilly HDd Carms HDd Ceredigion HDd Pembs Appendix 1 Cardiac Rehabilitation Population 504, 457 466,036 290,008 131,313 561,420 374,741 Total WTE by LHB 19.1 6.27 14.52 3.3 22.6 15.9 1.0 WTE per 100/1000 26 74 20 40 25 24 Total WTE by Locality 5.3 3.6 10.2 6.27 4.66 9.86 3.3 9.75 4.45 5.0 3.4 10.5 2.6 2.8 A designated team leader ensuring: NSF Quality Requirements Development of CR services Coordination of CR services Draft V1.1 Page 5 of 8
HDd ABHB PTHB RCT 1.0 WTE per 100/1000 Total WTE C&V ABM 0 20 40 60 80 In regards to the number of WTE per 100/1000 of population, C&V have the least number with 1.0 WTE per 74.3 (100/1000), RCT the highest with 1.0 WTE per 19.9 (100/1000). The remaining LHBs range between 39.7 and 23.5. When considering the staffing level for each LHB account needs to be taken of the demography profile. ABHB has some of the most deprived areas and the highest levels of CHD in the UK Blaenau Gwent, Newport East and West and Caerphilly North. Living with heart disease Cardiac rehabilitation is a structured set of services that enables people with heart disease to have the best possible help (physical, psychological and social) to preserve or resume their optimal functioning in society. Evidence based guidelines recommend that cardiac rehabilitation should be equally accessible and relevant to all patients after an MI, particularly people from groups that are less likely to access this service. The latest annual statistical report of the National Audit of Cardiac Rehabilitation calls for average uptake across all in-scope conditions to be above 60 per cent. This presents a huge challenge based on current service capacity and when patients are presenting with more complex needs in terms of co-morbidities. Draft V1.1 Page 6 of 8
The table below shows cardiac rehabilitation patient activity over a three year period with the percentage attrition from referral to assessment and the percentage uptake (attendance) based on eligible patients. Caerphilly 2009/10 2010/11 2012/13 Referred 270 243 354 Eligible 230 (85%) 209 (86%) 282 (79%) Assessed 112 (41%) 105 (43%) 195 (55%) Attended 100 (37%) 87 (35%) 114 (32%) % Uptake based on eligible patients 43% 35% 40% Newport (no 2009/10 2010/11 2012/13 heart failure) Referred 535 732 613 Eligible 390 (72%) 545 (74%) 523 (85%) Assessed 339 (63%) 353 (48%) 275 (44%) Attended 203 (37%) 291 (39%) 194 (31%) % Uptake based on eligible patients 52% 53% 37% Nevill Hall 2009/10 2010/11 2012/13 Hospital Referred 515 446 841 Eligible 236 (45%) 313 (70%) 673 (80%) Assessed 220 (42%) 198 (44%) 295 (43%) Attended 121 (41%) 150 (33%) 264 (89%%) % Uptake 51% 47% 39% Draft V1.1 Page 7 of 8
Torfaen 2009/10 2010/11 2012/13 Referred 596 520 397 Eligible 311 (52%) 377 (72%) 349 (87%) Assessed 299 (50%) 267 (51%) 207 (59%) Attended 190 (31%) 181 (34%) 193 (93%) % Uptake 61% 48% 48% During 2012-13 the ABHB Cardiac Rehabilitation Service received 2,205 referrals and of these 83 per cent were eligible to be assessed prior to commencing cardiac rehabilitation. In total, 42 per cent of patients completed either a centre/ community based or home programme. This reflects the UK average uptake of 43 per cent. There is a higher completion rate in Nevill Hall and Torfaen where there is a higher staff to patient ratio. The percentage of patients who wait longer than 10 days (aspirational target) from referral to assessment is 95 per cent; under 6 weeks 85 per cent. Patients who attend cardiac rehabilitation have a lower readmission rate at 90 days post event than those who are eligible but declined to attend. During 2012/13, 19 cardiac rehabilitation patients were admitted to hospital within 90 days with a length of stay of 56 days. In contrast, the 66 patients who refused cardiac rehabilitation, during this period but were eligible to attend accrued a length of stay of 218 days. Outcomes following cardiac rehabilitation, for both men and women led to positive changes in smoking cessation, physical activity, anxiety and depression and maximal pharmacological management. Dr Jackie Austin Nurse Consultant in Heart Failure and Cardiac Rehabilitation November 2013 Draft V1.1 Page 8 of 8