Developing rehabilitation for people with heart failureEvolving services in Newcastle upon Tyne

Christine Baker

In the beginning.Increasing prevalence of heart failurePeople with heart failure are frequently admitted to hospitalHeart failure is linked with poor prognosis and significant impact on everyday life. Growing evidence base:Exercise is safe and beneficial for people with heart failureNSF for CHD lists cardiac rehabilitation, risk factor advice, physical activity and psychosocial interventions as key interventions for people with heart failure

Figure 1 Hazard ratios and 95% confidence intervals for the individual studies for the effect of exercise training on risk of death . (ExTraMatch collaborative, BMJ, 2004)

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In Newcastle upon Tyne:In 2003 there was no rehabilitation service for people with heart failureA group was set up to address heart failure in the acute hospitals trust supported piloting a specific programmeWe had available resources within the acute Hospitals TrustA rehabilitation facility An experienced multi-disciplinary team

RVI rehab teamCardiac rehabilitation nursePhysiotherapist and physiotherapy supportOccupational therapistPharmacist, cardiologist, psychologist, dietician providing flexible inputAdministration support

An evolving model service user views1. Information needsIndividually relevant informationFacts about heart failureCoping with heart failureLifestyle changeDealing with othersPractical advice

Process: involve family members written informationgroup discussion (not talks) share information

2. Physical activityGoal to increase stamina and improve tolerance for exercise so not so tiredNeed for individualised exerciseHome exercise planSomething to do dailyGroup to provide support

3. Relaxation4. Time for peer support

Programme modelCondition (Heart failure) and evidence-basedTo help participants develop knowledge, skills and confidence to improve and sustain achievable health and functional activity.16 weekly sessions (2 hours) Up to 12 participants, partners invitedCollaborative: participants actively involved in planning programme, goal setting and monitoring progress

Individual reviewsA facilitated, personally set home-based exercise programme, developed and practiced at rehab.Activity plan and home diary to record and monitor activityRelaxation approaches demonstratedProgramme of discussion topics

Discussion topicsUnderstanding heart failureTaking control of symptomsAdjusting and copingManaging at homeMedicationApproaches to food and eatingExercise what can I doSocial support and community resources

Participants: recruitment and inclusion criteriaPotential participants identified by cardiologist or ward sisterNYHA class 2 or 3LV systolic dysfunction underlies heart failureStable for 4 weeksAngina no worse than CCS 3, and been assessedReviewed in cardiology clinicPeople with devices can be included

Exclusion criteriaNYHA class 4Severe angina/ischemiaUncontrolled heart failure, worsening symptomsChange in treatment due to worsening conditionBP < 90 mmHg systolic, or < 100 if associated dizzinessResting heart rate>100 beats/minUncontrolled arrhythmiasFebrile illnessCardiologist considers unsuitable

Evaluation The participants 4 men, 3 womenAged 43 79 yearsClass 3-4: 4 Left ventricular systolic dysfunction,

2 cardiomyopathyEjection fraction 20 72%Co-morbidity:

History of CHD (5), renal impairment (3), asthma (2), diabetes(2), Hyperthyroidism (2), Obesity (3), Peripheral vascular disease(1)

Attendance2 did not engage in group2 died in course of programme3 regularly attended whole programmeFamily members attended

Relevant past medical history (NYHA class, cause of heart failure, ejection fraction, exercise tolerance testMedication WeightOrthopnoea (numbers of pillows to sleep)Nocturnal dyspnoeaLeg fatigueOccupational therapy functional assessmentShuttle walk test Hospital Anxiety and Depression ScalesMinnesota Living with Heart Failure QuestionnairePersonal goalsAny recent worsening of symptoms (ankle swelling, fatigue, dizziness, shortness of breath, sleep problems) Resting blood pressure, heart rate, SaO2, respiratory rate

Participant

Measure

Pre-course

Post-course

1

Shuttle walk test

100m

210m

HADS - anxiety

1 (non-case)

4 (non-case)

HADS - Depression

1 (non-case)

2 (non-case)

Minnesota Living with HF

missing

40

2

Shuttle

300m

470m

HADS Anxiety

8 (non-case)

8 (non-case)

HADS Depression

2 (non-case)

4 (non-case)

Minnesota

20

17

3

Shuttle

80m

150m

HADS Anxiety

10 (borderline)

15 (caseness)

HADS Depression

4 (non- case)

3 ( non case)

Minnesota

37

31

4

Shuttle

10m

/

(died)

HADS Anxiety

5 (non-case)

/

HADS Depression

13 (caseness)

/

Minnesota

76

/

5

Shuttle

30m

/

HADS Anxiety

17 (caseness)

/

HADS Depression

10 (borderline)

/

Minnesota

61

/

6.

Shuttle

20m

/

(died)

HADS Anxiety

14 (caseness)

/

HADS Depression

10 (caseness)

/

Minnesota

49

Goal achievementCommon goals:To improve confidenceTo understand conditionTo increase energy levelsTo learn what I can do and how far to goTo take up a specific activityTo have a practical need met

Participants reported a good degree of goal attainment

Participant feedbackSemi-structured interviewAltogether positiveConstructive:Programme offered at diagnosisOpportunity to attend at intervals in futureIssue of prognosis, palliative care and deathsIssue of maintenanceIssue of support for family members

Staff feedbackReferrals too few Class 3 and 4: address referralCollaborative approach -individual goal setting -home-based programme worked wellDevelop rolling programme and flexible intervals for participants address maintenance/community linksDevelop written informationEvaluation Formal and sessional evaluation OK - capture self-efficacy Confidence and experience of staff has developed

Next stepsFurther developing as a rolling programmeCardiologists and BHF heart failure nurses involved in recruitmentEvolving links with community services re. maintenanceContinuing to evaluate

Taking control of Heart Failure

A community development project

Taking control of Heart FailureA community development projectBased in inner west of Newcastle-upon TyneSupported by grant from Health Action Zone: partnership funding for preventative programmesPartnership of community and health (PCT) providers

Taking control of heart failureModelBased on community development methods and principals. Innovation-based.Objective: to empower people to take more control of their lives to add valueFundamentally a quality of life programme, not a disease based programmeParticipants determine programme structure and outcome evaluation (no physiological measures)

Taking control of heart failureProcess2 BHF funded HF nurses working with GPs and practice nurse IHD leads from 2 practices32 people with class 2 heart failure identifiedWritten invitation to participate follow-up telephone callBHF nurses visiting willing people at home to meet, provide information and discuss group.Invitation to group.

Taking control of Heart FailureProgramme2 closed groupsTen weekly sessionsFacilitated by community development worker with experience in such projects and group facilitationContent directed by groupPotential involvement of local cardiac rehab team pharmacist, psychologist, exercise specialists, nutritionist

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