chf rapid guide 12th february 2012

7/31/2019 CHF Rapid Guide 12th February 2012

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Public Health Wales 1000 Lives + Chronic Heart Failure H2G

Author

Primary Care Quality and Information Service

Date

February 2012

Status; Final

Version; 1 1Intended audience: Public (Internet) / NHS

(Intranet) PHW (Intranet) / PCQIS

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 successfullyimplement 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


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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 inany of the primary care 1000 Lives + topics, please click on the following webpage toregister your interest: Practice Registration Form.

This document is not intended to be a complete reference manual. This guide shouldbe used alongside the 1000 Lives + How to Guides to support the successfulimplementation of the programmes interventions. 1000 Lives Plus.
http://nww.nphs-cgtool.wales.nhs.uk/http://nww.nphs-cgtool.wales.nhs.uk/http://www.1000livesplus.wales.nhs.uk/homehttp://www.1000livesplus.wales.nhs.uk/homehttp://www.1000livesplus.wales.nhs.uk/homehttp://nww.nphs-cgtool.wales.nhs.uk/


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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 prevalenceof 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 producea CHF driver diagram (See page 4) to summarise desired outcomes and how theycan 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 ofcare bundles with evidence basedinterventions 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 compliancewith all elements of a care bundle) which is evidently linked to an outcome (such asan increase in the numbers of referrals for echocardiograph). Both process andoutcome 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 storyand build the case and/or argument to change practice in order to improveoutcomes.3

Practices may wish to allocate their own standards to the recommended process

measures (data measures) on Pages 5-7.


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

patients who are symptomatic post MI

Aim Driver

Diagnosis &Investigation

Effective drugtherapy

Reducing the Riskof infections

ReduceMorbidity

forpatientswith CHF(LVSD)

Care Bundle 4

Offer Influenza and PneumococcalImmunisation

Care Bundle 2

Treat all who can tolerate therapy andfor whom there are no contraindications,

initially with an ACE/ARBs Inhibitor at low

dose, titrating upwards to maximum

Use licensed beta-blocker therapy forpatients with Left Ventricular Systolic

Dysfunction (LVSD), where there are no

contra-indications and optimisation of dose

to maximum tolerated (resting heart rate


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Process MeasuresTo 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 & InvestigationTotal

NumberDenominator %

Relevant suggestedREAD Codes

Care

Bundle

One

(i) Patients with a coded diagnosis of leftventricular systolic dysfunction (LVSD) G5yy9 Left ventricular systolic dysfunctionG581.. Left ventricular failure

(ii) Patients with LVSD who have had anechocardiograph

All patientswith new

diagnosis ofLVSD withinthe agreed

three monthtime frame

5853.11 U-S heart scan

8HQ7. Referral for echocardiography

56F1. Echocardiogram declined

585R. Echocardiogram normal5C20. Echocardiogram equivocal585g. Echocardiogram shows left

ventricular diastolic dysfunction

585f. Echocardiogram shows left

ventricular systolic dysfunction

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

Any patientwho has ever

had an MI

G30.. acute myocardial infarction

G32.. old myocardial infarction


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Driver: Diagnosis & InvestigationTotal

NumberDenominator %

Relevant suggestedREAD Codes

CareBundle

One

(contd.)

(iv) Patients with LVSD who have had an ECG(Excluding those who have had a MI)

All patients

with new

diagnosis of

LVSD and who

have not had a

MI within the

agreed threemonth time

frame

321B. 12 lead ECG

32... Electrocardiography

3211. ECG requested

3216. ECG normal

R1431 [D]Electrocardiogram (ECG) abnormal32140 Ambulatory ECG normal

(v) Patients with LVSD and who have not had aMI with a normal ECG who have Plasma B-Type Natriuretic Peptide (BNP) levels recorded

All patientswith new

diagnosis and

who have not

had an MI

44AP. Serum pro-brain natriuretic peptide level

44AN. Plasma pro-brain natriuretic peptide level


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Data Summary Chronic Heart Failure (CHF) Care Bundle Two

Timeframe of data collection ________________

Driver: Effective Drug TherapyTotal

NumberDenominator % Relevant suggested READ Codes

Care

Bundle

Two

Patients with Left Ventricularsystolic dysfunction (LVSD)without contraindications forACE-inhibitor prescribed fulldose ACE-inhibitor

All patientswith LVSDminus CI to

ACEI

8I28. Angiotensin converting enzyme inhibitors contraindicated

U60C4 [X]Angiotensin-converting-enzyme inhibitors causing

adverse effects in therapeutic use

8I3P. Angiotensin II receptor antagonist14LM H/O Angiotensin converting enzyme inhibitor allergy

ZV14D[V] Personal history of ACE inhibitor allergybk3.. 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


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Driver: Effective DrugTherapy

TotalNumber

Denominator % Relevant suggested READ Codes

Care

Bundle

Two

(contd.)

Patients with LVSDand withoutcontraindicationsprescribed full dosebeta-blocker therapy(resting pulse rate


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Driver: Effective Drug TherapyTotal

NumberDenominator % Relevant suggested READ Codes

Care

Bundle

Two

(contd.)

Patients who remain

NYHA 2-4 after

optimisation of

ACEI/ARB2 and beta

blocker prescribed

aldosterone antagonist

All patientswith LVSD

with NYHA 2-4 who have

triedACEI/ARBSand BetaBlockers

b43.. SPIRONOLACTONE

b45..% EPLERENONE

662f NYHA stage I

662g NYHA stage II

662h NYHA stage III

662i NYHA stage IV

8I2L. Spironolactone contraindicated

TJE44 Adverse reaction to spironolactoneU60E1[X] Mineralocorticoid antagonists [aldosterone antagonists]

causing adverse effects in therapeutic use

8I3K0 Spironolactone declined

8I3K. diuretic declined


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Data Summary Chronic Heart Failure (CHF) Care Bundle Three

Timeframe of data collection _____________________

Driver: Effective clinician/patient Partnership

TotalNumber


Care

Bundle

Three

Patients with a selfmanagement plan

All patientswith a diagnosisof LVSD

8CMK. Has heart failure management plan8CL3. Heart failure care plan discussed with patient


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Data Summary Chronic Heart Failure (CHF)Care Bundle Four

Timeframe of data collection _____________________

Driver: Reducing the risk ofinfection

TotalNumber


Care

Bundle

Four

LVSD patients with

documentedimmunisation for

pneumococcalpneumonia All patients

diagnosedwith LVSD

n4b.. PNEUMOCOCCAL VACCINE

65720 Pneumococcal vaccination given657P. 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

LVSD patients withdocumented

immunisation forinfluenza in the last

18 months

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


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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 inyour practice to support the implementation of the Driver Diagram. Essentialquestions that form the basis for the Model for Improvement are;

1. What are we trying to accomplish?2. How will we know when we have accomplished what we set out to do?3. 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 asmall-scale test of change (or pilot). Testing allows us to adapt actions to particularsettings. To test a new procedure or technique, the practice need to plan, do, studyand 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 betweenwhat you currently do and what evidence based guidelines suggest you do or whereyou 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 onthem. However, where they are different from your usual practice, explore theseguidelines/recommendations in more detail. Work out (i.e. plan) how and what youcould test/try that would make the differences smaller.

DoCarry out the plan and collect information on what worked well and what hasntworked so well.

To assess the application of the interventions within the driver diagram, use theprocess 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 giveyou a more regular idea of how well you are doing.

The practice may find the information/data needed is not currently being collected inan easily retrievable format (or coding). If so, you may wish to use standard codingor use of a template as your first test of change.
http://www.wales.nhs.uk/sites3/Documents/781/T4I%20%281%29%20How%20to%20%20Improve%20%28Feb%202011%29%20Web.pdfhttp://www.wales.nhs.uk/sites3/Documents/781/T4I%20%281%29%20How%20to%20%20Improve%20%28Feb%202011%29%20Web.pdfhttp://www.wales.nhs.uk/sites3/Documents/781/T4I%20%281%29%20How%20to%20%20Improve%20%28Feb%202011%29%20Web.pdf


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Study

Gather relevant team members as soon as possible after the test (Do) for a shortinformal meeting. Analyse the information gathered and review the expected outcomethe new process or technique against what actually happened. Questions that will helpyou 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. Agreethe changes. If you feel the outcome measures are no longer appropriate, pleasecontact Primary Care Quality Information Service.

Continue testing in this way, refining the new procedure or technique, Once all theinterventions are being applied to 90% of eligible patients, share your ideas andactions with other practices.


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References

1. National Clinical Guidelines Centre (2010) Chronic Heart Failure: The managementof chronic heart failure in adults in primary and secondary care (revised).

2. Healthcare Commission (2007) pushing the boundaries: improving services forpeople with heart failure. London: Commission for Healthcare Audit and Inspection

3. 1000 lives + Improving Care, delivering quality: How to Improve-The Guide forreliable and sustained Improvement (April 2011)