Public Health Wales

1000 Lives + Chronic Heart Failure H2G

Primary Care Chronic Heart Failure (Left Ventricular Systolic Dysfunction)

Rapid Improvement Guide

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.

VERSION 1 February 2012

Author Primary Care Quality and Information Service

Date February 2012

Status; Final

Version; 1

Intended audience: Public (Internet) / NHS (Intranet) PHW (Intranet) / PCQIS

Public Health Wales

1000 Lives + Chronic Heart Failure H2G

The purpose of this guide

This Rapid guide has been developed by the Primary Care Quality Information Service (PCQIS) and the 1000Lives + team to support general practices in reviewing their current processes for providing care to patients with Heart Failure arising from left ventricular systolic dysfunction.

How do practices get involved?

PCQIS have set up an online registration process for practices who wish to engage in any of the primary care 1000 Lives + topics, please click on the following webpage to register your interest: Practice Registration Form. This document is not intended to be a complete reference manual. This guide should be used alongside the 1000 Lives + How to Guides to support the successful implementation of the programmes interventions. 1000 Lives Plus.

Author Primary Care Quality and Information Service

Date February 2012

Status; Final

Version; 1

Intended audience: Public (Internet) / NHS (Intranet) PHW (Intranet) / PCQIS

Public Health Wales

1000 Lives + Chronic Heart Failure H2G

1. What are we trying to accomplish?

Desired outcome to Reduce Morbidity for patients with CHF (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 Prevalence of recorded heart failure mostly falls short of predicted levels2 which could indicate that there is a largely unseen demand for investigations, clinical assessment and care. There are several types of heart failure. The strongest evidence base at present is for Left Ventricular Dysfunction (LVSD).

What should we be doing?

Primary Care Quality Information Service has used the evidence gathered to produce a CHF driver diagram (See page 4) to summarise desired outcomes and how they can be achieved. The driver diagram will help the practice translate a high level improvement goal into a logical set of underpinning goals (drivers). It captures an entire change programme in a single diagram and also provides a measurement framework for monitoring progress. The following driver diagram details a series of care bundles with evidence based interventions known to be effective in treating Chronic Heart Failure. All elements within the bundles should be implemented to maximise benefit. See data summary sheet page 6-8 for suggested READ codes and terms to support this guide.

2. How will we know that a change is an improvement?

In order to answer this the practice will need a defined process (such as compliance with all elements of a care bundle) which is evidently linked to an outcome (such as an increase in the numbers of referrals for echocardiograph). Both process and outcome data which are linked are essential to evaluate the effectiveness of change. The data the practice collect in real time can be used to tell the improvement story and build the case and/or argument to change practice in order to improve outcomes.3 Practices may wish to allocate their own standards to the recommended process measures (data measures) on Pages 5-7.

Author Primary Care Quality and Information Service

Date February 2012

Status; Final

Version; 1

Intended audience: Public (Internet) / NHS (Intranet) PHW (Intranet) / PCQIS

Public Health Wales

1000 Lives + Chronic Heart Failure H2G

Aim

Driver

What should we be doing

Care Bundle 1
Refer all patients with previous MI for echocardiography if not already done post MI * Patients presenting with persistent breathlessness should be clinically assessed for the possibility of Heart Failure Perform an ECG on all patients with suspected Heart Failure If ECG abnormal refer for echocardiograph If ECG normal measure Plasma B-Type Natriuretic Peptide (BNP) If BNP raised refer for Echocardiogram If AF present use CHADS2 score to assess need for anticoagulation

Diagnosis & Investigation

Care Bundle 2 Effective drug therapy

Treat all who can tolerate therapy and for whom there are no contraindications, initially with an ACE/ARBs Inhibitor at low dose, titrating upwards to maximum Use licensed beta-blocker therapy for patients with Left Ventricular Systolic Dysfunction (LVSD), where there are no contra-indications and optimisation of dose to maximum tolerated (resting heart rate <65 b.p.m. Provide aldosterone antagonist to all pts who are NYHA 2-4 after optimisation of ACE1/ARBs and BB

Reduce Morbidity for patients with CHF (LVSD)

Effective clinician/patient Partnership

Care Bundle 3
Patients should be given verbal and written information about their condition Patients should have a clear discharge plan from secondary care and an agreed self management plan

Reducing the Risk of infections

Care Bundle 4
Offer Influenza and Pneumococcal Immunisation

* If unsure, check through hospital letters for mention of a recent echo report prior to referral for the

patients who are symptomatic post MI

Author Primary Care Quality and Information Service

Date February 2012

Status; Final

Version; 1

Intended audience: Public (Internet) / NHS (Intranet) PHW (Intranet) / PCQIS

Public Health Wales

1000 Lives + Chronic Heart Failure H2G

Process Measures To assess the application of the interventions, use the following process measures for your collection of data: Note: Some elements of the care bundle may be difficult to measure in practice; in these cases a proxy measure can be used Data Summary Chronic Heart Failure (CHF) Care Bundle One Timeframe of data collection __________________ Driver: Diagnosis & Investigation (i) Patients with a coded diagnosis of left ventricular systolic dysfunction (LVSD) All patients with new diagnosis of LVSD within the agreed three month time frame Any patient who has ever had an MI Total Number Denominator % Relevant suggested READ Codes
G5yy9 Left ventricular systolic dysfunction G581.. Left ventricular failure 5853.11 8HQ7. 56F1. 585R. 5C20. 585g. 585f. U-S heart scan Referral for echocardiography Echocardiogram declined Echocardiogram normal Echocardiogram equivocal Echocardiogram shows left ventricular diastolic dysfunction Echocardiogram shows left ventricular systolic dysfunction acute myocardial infarction old myocardial infarction

Care Bundle One

(ii) Patients with LVSD who have had an echocardiograph

(iii) Patients who have had a MI should have an Echocardiogram after the event

G30.. G32..

Author Primary Care Quality and Information Service

Date February 2012

Status; Final

Version; 1

Intended audience: Public (Internet) / NHS (Intranet) PHW (Intranet) / PCQIS

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1000 Lives + Chronic Heart Failure H2G

Driver: Diagnosis & Investigation

Total Number

Denominator
All patients with new diagnosis of LVSD and who have not had a MI within the agreed three month time frame All patients with new diagnosis and who have not had an MI

Relevant suggested READ Codes

(iv) Patients with LVSD who have had an ECG (Excluding those who have had a MI)
Care Bundle One (contd.)

321B. 32... 3211. 3216. R1431 32140

12 lead ECG Electrocardiography ECG requested ECG normal [D]Electrocardiogram (ECG) abnormal Ambulatory ECG normal

(v) Patients with LVSD and who have not had a MI with a normal ECG who have Plasma BType Natriuretic Peptide (BNP) levels recorded

44AP. Serum pro-brain natriuretic peptide level 44AN. Plasma pro-brain natriuretic peptide level

Author Primary Care Quality and Information Service

Date February 2012

Status; Final

Version; 1

Intended audience: Public (Internet) / NHS (Intranet) PHW (Intranet) / PCQIS

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1000 Lives + Chronic Heart Failure H2G

Data Summary Chronic Heart Failure (CHF) Care Bundle Two Timeframe of data collection ________________ Driver: Effective Drug Therapy Total Number Denominator %
8I28. U60C4

Relevant suggested READ Codes

Angiotensin converting enzyme inhibitors contraindicated [X]Angiotensin-converting-enzyme inhibitors causing adverse effects in therapeutic use 8I3P. Angiotensin II receptor antagonist 14LM H/O Angiotensin converting enzyme inhibitor allergy ZV14D[V] Personal history of ACE inhibitor allergy bk3.. to bk5z. Losartan, Valsartan, Irbesartan bk7.. to bk9z. Candesartan, Telmisartan, Eprosartan bkB..% Olmesartan bkD..% Amlodipine and Valsartan bkC..% Hydrochlorothiazide and Olmsartan 8I64. Angiotensin converting enzyme inhibitor not indicated

Care Bundle Two

(i) Patients with Left Ventricular systolic dysfunction (LVSD) without contraindications for ACE-inhibitor prescribed full dose ACE-inhibitor

All patients with LVSD minus CI to ACEI

Author Primary Care Quality and Information Service

Date February 2012

Status; Final

Version; 1

Intended audience: Public (Internet) / NHS (Intranet) PHW (Intranet) / PCQIS

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1000 Lives + Chronic Heart Failure H2G

Driver: Effective Drug Therapy

Total Number

Denominator

%
bd... TJC6. U60B7

Relevant suggested READ Codes

BETA-ADRENOCEPTOR BLOCKERS Adverse reaction to beta-blockers [X]Beta-adrenoreceptor antagonists causing adverse effects in therapeutic use, not elsewhere classified 242.. O/E - pulse rate bdf..% Bisoprolol fumarate bdl..% Carvedilol bdm..% Nebivolol 14LL. H/O beta-blocker allergy U60B9 Adverse reaction to bisoprolol U60BA Adverse reaction to carvedilol U60BB Adverse reaction to nebivolol ZV14C Personal history of beta-blocker allergy ZVu6i Personal history of allergy to bisoprolol ZVu6o Personal history of allergy to carvedilol ZVu6q Personal history of allergy to nebivolol 8I26. Beta-blocker contraindicated 8I73. Beta-blocker not tolerated 8I2g. to 8I2i. Bisoprolol, Carvedilol, Nebivolol contraindicated 8I7K. to 8I7M. Bisoprolol, Carvedilol, Nebivolol not tolerated 8IAS. to 8IAV. Bisoprolol, Carvedilol, Nebivolol therapy refused 8I36. Beta-blocker therapy refused

Care Bundle Two (contd.)

Patients with LVSD and without contraindications prescribed full dose beta-blocker therapy (resting pulse rate <65 b.p.m.)

All patients with LVSD minus CI to Beta Blockers

Author Primary Care Quality and Information Service

Date February 2012

Status; Final

Version; 1

Intended audience: Public (Internet) / NHS (Intranet) PHW (Intranet) / PCQIS

Public Health Wales

1000 Lives + Chronic Heart Failure H2G

Driver: Effective Drug Therapy

Total Number

Denominator

%
b43.. b45..% 662f 662g 662h 662i 8I2L. TJE44 U60E1[X] 8I3K0 8I3K.

Relevant suggested READ Codes

SPIRONOLACTONE EPLERENONE NYHA stage I NYHA stage II NYHA stage III NYHA stage IV Spironolactone contraindicated Adverse reaction to spironolactone Mineralocorticoid antagonists [aldosterone antagonists] causing adverse effects in therapeutic use Spironolactone declined diuretic declined

Care Bundle Two (contd.)

Patients who remain NYHA 2-4 after optimisation of ACEI/ARB2 and beta blocker prescribed aldosterone antagonist

All patients with LVSD with NYHA 24 who have tried ACEI/ARBS and Beta Blockers

Author Primary Care Quality and Information Service

Date February 2012

Status; Final

Version; 1

Intended audience: Public (Internet) / NHS (Intranet) PHW (Intranet) / PCQIS

Public Health Wales

1000 Lives + Chronic Heart Failure H2G

Data Summary Chronic Heart Failure (CHF) Care Bundle Three Timeframe of data collection _____________________ Driver: Effective clinician/ patient Partnership Care (i) Bundle Three Patients with a self management plan Total Number Denominator All patients with a diagnosis of LVSD % Relevant suggested READ Codes 8CMK. Has heart failure management plan 8CL3. Heart failure care plan discussed with patient

Author Primary Care Quality and Information Service

Date February 2012

Status; Final

Version; 1

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1000 Lives + Chronic Heart Failure H2G

Data Summary Chronic Heart Failure (CHF)Care Bundle Four Timeframe of data collection _____________________ Driver: Reducing the risk of infection LVSD patients with documented immunisation for pneumococcal pneumonia LVSD patients with documented immunisation for influenza in the last 18 months Total Number Denominator % Relevant suggested READ Codes
n4b.. PNEUMOCOCCAL VACCINE 65720 Pneumococcal vaccination given 657P. Pneumococcal vaccine given by another provider U60J8. Pneumococcal vaccination causing adverse effect in therapeutic use ZV14G Personal history of pneumococcal vaccination allergy & 14LR. H/O: pneumococcal vaccine allergy 65E... Influenza vaccination n47..% Influenza vaccine ZV048 Influenza vaccination 14LJ. H/O influenza vaccination allergy U60K4 [X]Influenza vaccine causing adverse effects in therapeutic use ZV14F [V]Personal history of influenza vaccine allergy

Care Bundle Four

All patients diagnosed with LVSD

Author Primary Care Quality and Information Service

Date February 2012

Status; Final

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1000 Lives + Chronic Heart Failure H2G

3. What change can we make that will result in improvement?

PDSA (Plan, Do, Study, Act) cycles are a process to assist with making changes in your practice to support the implementation of the Driver Diagram. Essential questions that form the basis for the Model for Improvement are; 1. 2. 3. What are we trying to accomplish? How will we know when we have accomplished what we set out to do? What will we test/try in order to produce the improvement we aim to achieve?

Even if something has been shown to work in other settings, take the time to do a small-scale test of change (or pilot). Testing allows us to adapt actions to particular settings. To test a new procedure or technique, the practice need to plan, do, study and act as explained below. (How to Improve Guide for more information). Use the following PDSA (Plan, Do, Study, Act) cycle to test, implement and replicate each intervention within the driver diagram (Page 4).

Plan
Plan what you are going to do differently? In other words as a practice (or at least one GP with one other staff member), choose an area where you know or think there may be a significant gap between what you currently do and what evidence based guidelines suggest you do or where you feel that optimum care is not being provided to all those who may benefit Where the guidelines and your practice are consistent, spend little or no time on them. However, where they are different from your usual practice, explore these guidelines/recommendations in more detail. Work out (i.e. plan) how and what you could test/try that would make the differences smaller.

Do

Carry out the plan and collect information on what worked well and what hasnt worked so well. To assess the application of the interventions within the driver diagram, use the process measures (data measures) on Page 5-7: Continuous data collection will be collected mainly via the Audit+ software. Data will be analysed and fed back to practices and local networks. The first collection of your data will provide a baseline of current performance. Thereafter running and reviewing the data collection at an agreed frequency will give you a more regular idea of how well you are doing. The practice may find the information/data needed is not currently being collected in an easily retrievable format (or coding). If so, you may wish to use standard coding or use of a template as your first test of change.

Author Primary Care Quality and Information Service

Date February 2012

Status; Final

Version; 1

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1000 Lives + Chronic Heart Failure H2G

Study
Gather relevant team members as soon as possible after the test (Do) for a short informal meeting. Analyse the information gathered and review the expected outcome the new process or technique against what actually happened. Questions that will help you include the following: What is the information telling us? What worked and what didnt work? What should be adopted, adapted, or abandoned?

Act
Use this new knowledge (information, data and study) to plan the next test. Agree the changes. If you feel the outcome measures are no longer appropriate, please contact Primary Care Quality Information Service. Continue testing in this way, refining the new procedure or technique, Once all the interventions are being applied to 90% of eligible patients, share your ideas and actions with other practices.

Author Primary Care Quality and Information Service

Date February 2012

Status; Final

Version; 1

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Intended audience: Public (Internet) / NHS (Intranet) PHW (Intranet) / PCQIS

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1000 Lives + Chronic Heart Failure H2G

References
1. National Clinical Guidelines Centre (2010) Chronic Heart Failure: The management of chronic heart failure in adults in primary and secondary care (revised). 2. Healthcare Commission (2007) pushing the boundaries: improving services for people with heart failure. London: Commission for Healthcare Audit and Inspection 3. 1000 lives + Improving Care, delivering quality: How to Improve-The Guide for reliable and sustained Improvement (April 2011)

Author Primary Care Quality and Information Service

Date February 2012

Status; Final

Version; 1

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Intended audience: Public (Internet) / NHS (Intranet) PHW (Intranet) / PCQIS