ZA Bhutto Heart Failure Program part III.pdf
- 1. Shaheed Zulfiqar Ali Bhutto First Multidisciplinary Value based Heart Failure Program & network Sindh Pakistan. This Unique manual is dedicated to Shaheed Z A Bhutto Building Heart Failure Program to improve heart failure services in Sindh , Pakistan Dr Asadullah Khan Soomro MBBS , Diploma Cardiology ,Royal Brompton National Heart & Lung Institute University of London Adult Cardiologist & Heart Failure Specialist , Altamash General Hospital Clifton block 1 Karachi Pakistan Email , hssbasadsoomro@gmail.com : Mobile 0092 302 2308718
- 2. Shaheed Zulfiqar Ali Bhutto First Multidisciplinary Value based Heart Failure Program & network Sindh Pakistan. “GDMT Shift from inpatient to ambulatory outpatient Setting “
- 3. Part III Shaheed Zulfiqar Ali Bhutto First Multidisciplinary Value based Heart Failure Program & network Sindh Pakistan. Patients Operational Consideration
- 4. KAMC Heart Failure Organizational Structure One Heart Failure Governor 2 to 3 Heart failure cardiologists Heart Failure governors responsibility is to supervise multidisciplinary HF program, he should be preferably heart failure cardiologist / dedicated cardiologist interested in heart failure. Since HF program has four components , one HF cardiologist will take care of inpatient heart failure unit and intra / extra departmental consultations and emergency heart failure services up to 4 pm. 2nd HF cardiologist will look after multidisciplinary specialized heart failure clinics and Virtual community heart failure services. 3rd HF cardiologist will cover deficiencies and to cover services during vacations. Heart failure nurse coordinators will rotate to cover nurse lead HF out patient clinics, inpatient heart failure unit services, emergency department HF services and assist in virtual community heart failure services. HF clinical pharmacist ,dieticians, educationist, heart failure cardiac rehabilitation and exercise physiologist ,last not the least social worker and councillor 3 to 6 Heart Failure Nurse Coordinators Dieticians Clinical Pharmacists Cardiac Rehabilitation / Exercise physiologist Heart Failure Educationist Social workers/ Councilor Heart Failure Organizational Structure
- 5. KAMC HEART FAILURE CARDIOLOGIST Family Physician Emergency Physician Clinical cardiologist Non Invasive Interventional Cardiologist Cardiac Surgeon Electrophysiologist Anesthesiologist Imaging specialist Cardiac Radiologist Cardiac Pathologist CHD HF &Cardiac Morphologist Diabetologist Nephrologist Pulmonologist Cardiac Rehabilitation Cardio-oncologist Neurologist Dentist Heart Failure Nurse Heart Failure Educationist Clinical pharmacist Exercise physiologist Dietecian Cardio-obstetrician/neonatologist Heart Failure Programme Multidisciplinary Team
- 6. LHFS HF patients operational considerations Operational consideration, Focus on optimizing the structure & efficiency of the programme. 1) Determine Specific Patient Population. 2) Determine Triggers for expected Referral. 3) Assess physical location of clinic 4) Appoint Appropriate clinic Leadership 5) Determine clinic Staff model 6) Create an appointment structure 7) Develop clinical practice protocol 8) Develop Relationship with Relevant Subspecialties Heart Failure Patients Operational Consideration
- 7. LHFS HF patients operational considerations 09) Develop partnership with frequently used clinical services. 10) Develop a Technology & virtual visit infrastructure ( Optional ) 11) Establish a Mechanism for patient follow up 12) Create Hospital Coverage Plan 13) Determine mechanism for continuous Quality Improvement 14) Obtain Appropriate Accreditations .JCI ,AHA & ACC (Optional ) 15) build or join Research Network 16) Develop Business Plan. Heart Failure Patients Operational Consideration
- 8. LHFS Specific Patient Population 1) We have three to four levels of heart failure services like , a) Level I Community health care , with only out patient clinics capability b) Level II , general hospitals with Emergency department, Inpatient and outpatient services , without Cath lab and PCI . c) Level III , all as in level 11 but without advanced heart failure therapies ( LVAD/OHT ) d) Level IV , KAMC ,all level three with advanced MDHFP and advanced HF therapies capability (like ICD/CRTD/MV clip/LVAD & heart transplant ) . 2) Every HF service should be prepared to receive stage B and stage C HF with reduced or preserved EF. Many have comorbidities too. Since every service has limitations especially level I to III , Therefore we need to develop referral criteria amongst Makkah healthcare cluster & HF network, especially early referral of heart failure stage D. Specific Patient Population
- 9. LHFS Inter-hospital triggers for referral 1) Recognizing that not all HF practices will directly offer advanced HF therapies ,so we need friendly referral framework and publicize it ( Like I -NEED- HELP & referral criteria tables). 2) We have all the services in Holy Makkah healthcare cluster except heart transplant & Cardiac /HF Rehabilitation. 3) In preparation for heart transplant its mandatory to have multidisciplinary heart failure programme ( MDHFP ) and network to connect all services , with cardiac rehabilitation and last not the least , heart failure teaching ,training ( physicians & nurses ) and research . Inter hospital Triggers for referral
- 10. LHFS Inter-hospital Referral Criteria to MDHFP 1 2 3 4 5 6 7 New onset ( De-Novo ) heart failure , regardless of LVEF for evaluation of etiology & GDMT disease management Chronic heart failure with one of the high risk feature ( see high risk table ) like persistent FC 111 IV symptoms . Symptomatic hypotension,( < 90 mm ) , Recurrent ER Visits or hospitalization, Major organ dysfunction & others. To Assist with GDMT like ARNI and comorbid conditions ( like CKD and hyperkalemia ) Persistently reduced EF < 35% despite GDMT for > 3 months for consideration of device therapy. Second opinion regarding etiology ( Ischemic HF , Valve diseases, cardiomyopathies ) Annual Review for patients with established advanced HF for evaluation of advanced therapies . Assess the possibility of participation in clinical trials . Inter Hospital Referral Criteria to MDHFP
- 11. LHFS 1 2 3 4 5 6 7 Need for chronic IV Inotropes / IV diuretics Persistent FC 111 IV symptoms of congestion or profound fatigue . Symptomatic hypotension, Systolic blood pressure ( < 90 mm ) Recurrent ER Visits or hospitalization for worsening HF ( ADCHF ) Major organ dysfunction Creatnine > 1.8 mg or BUN > 43 , Increasing passive liver congestion ( Hyperbilirubinemia ) Clinical deterioration , persistently raised BNP , increasing breathlessness, Edema ,inability to tolerate GDMT ( ACE,ARB,ARNI, beta blockers & MRA Spironolactone ) High mortality risk need advanced therapies ( Post cardiac arrest survivor) High risk chronic HF triggers for MDHFP
- 12. LHFS (I NEED HELP ) Decision making points to refer HF patient for advanced therapy I N E E D H E L P IV inotropes NYHA FC III /IV or persistently raised BNP End Organ Dysfunction ( renal & Liver ) LV Ejection Fraction < 35% Defibrillator shocks Hospitalization > 1 Edema despite escalating dose of diuretics Low blood pressure < 80, tachycardia Progressive intolerance or down titration of GDMT ( mainly Prognostic medications ) (I NEED HELP ) Decision making points to refer HF patient for advanced therapy
- 13. LHFS Appropriate Leadership One of the most important decision while organizing a multidisciplinary HF program amongst stakeholders, is effective leadership. “Dyad of a HF physician and administrative professional”. Physician is responsible for ensuring delivery of high quality ,safe ,evidence-based patient care. Physician encourages teamwork, maximizes productivity of the clinical team, and oversees clinician-driven resources use & staffing. Administrative Leader handles financial and supply chain management , market share analysis ,informatics infrastructure and medical records maintenance, billing ,capital planning and deployment. Appropriate Leadership
- 14. LHFS Determine HF programme staff Model Along with heart failure physician and assistants ,allied health professionals are important in ensuring the success of HF program, like • Clinical pharmacist • Registered nurse • Nutritionist • Psychologist • Palliative care • Physical therapist/exercise physiologist • Social worker • Financial Coordinator Advanced HF patients especially with an implanted hemodynamic monitoring device, post LVAD and heart transplant patients, need trained coordinators ( usually trained nurses ) who provide ongoing monitoring and support Determine HF programme Staff Model
- 15. LHFS HF patients Appointment structure To make best decisions , the HF team should consider establishing the total number of patients on different clinics .Visit structure and duration, time per patient ,may need to be tailored for individual patients per clinical judgement , as under . 1) New patient appointment ( RAHFC ) 2) Established diagnosis and HF stage for drug dose monitoring and dose titration ( GDMT or maximally tolerated ) at RHFC 3) Post discharge transitional care ,PDHFC ( early with in 2 weeks ) 4) Urgent care appointment ( Same day ) 5) Group Appointments for HF education /Cardiac rehabilitation classes Heart Failure Patient Appointment Structure
- 16. How soon should I see Newly Referred HF Patient Triage category/ Access target Clinical Scenario Emergency with in 24 hours • Acute severe myocarditis /Cardiogenic Shock • Transplant & Device evaluation of unstable patient. • New onset acute Pulmonary Edema • HF in setting of acute coronary syndromes Urgent < 2 Weeks Progressive /Decompensated heart failure. *New onset decompensated heart failure. *New progression to NYHA FC 1V HF. *Post Myocardial infarction HF/ Post hospitalization HF ER visit. *Heart Failure with severe valve disease Semi Urgent < 4 Weeks • New Onset heart failure FC 1 & 11 compensated. • HF with NYHA class 11 & 111 symptoms • Worsening HF despite treatment . • Severe valve disease with mild symptoms with renal impairment or hypotension Routine schedule 6-12 Weeks Chronic heart failure FC11 Structural heart disease with NYHA FC 1/ or asymptomatic stage B How soon should I see Newly Referred Heart Failure Patient
- 17. High Risk HF patients Follow up every 1-4 weeks /or visits may increase because of medication titration. Intermediate Risk HF patients. Every 1 to 6 months Low Risk HF patients Every 6 -12 months • Recent HF hospitalization • NYHA class 111 or 1V symptoms • New onset heart failure • During titration of HF medications • Complications of HF therapy ,like renal and electrolyte imbalance & hypotension. • Need to down titrate or discontinue beta blockers/ACE or ARB /ARNI • Severe concomitant and active illness like COPD exacerbation. • Frequent ICD shocks /Infections. No Clear high /low risk features of HF. • No hospitalizations in past one year. • NYHA Class 1 or 11. • No recent changes in medications. • Receiving optimal medical /device HF therapies. How Often Should My HF Patient Be Seen . ( Follow up frequency)
- 18. Suggested timing for measurement of LV Ejection Fraction according to scenario. Clinical Scenario Timing of Measurement Modality of Measurement Comments New onset HF Immediately or with in 2 weeks as baseline assessment. Preferably Echo when available/ MUGA/CMRI 70% request echo 30% other modalities according to clinical judgement Following titration of triple therapy. Or for ICD & CRT implantation. 3 months after completion of titration Echo or MUGA or CMRI Preferably same modality LVEF after GDMT might improve ,obviating device therapy. Stable Heart Failure. After significant clinical event/HF admission 2 to 3 years if EF > 40% With in 30 days during hospitalization Echo, MUGA or CMRI. Echo, MUGA ,CMRI Or Cath if ACS For prognostic significance. If get worse need ICD/CRT. Helpful for EF, Valve regurgitation & RV SP. Suggested timing for measurement of LV Ejection Fraction according to scenario.
- 19. LHFS Heart failure being a complex syndrome ,therefore these patients should have access to clinical specialties within and outside of CV medicine .Although patient will be closely followed by HF physician to maintain primary care relationship, but adequate attention is paid to comorbid conditions and noncardiovascular preventive care. 1) General Cardiologist / general physician 2) Cardiothoracic surgeon 3) Electrophysiologist 4) Interventional cardiologist 5) Adult congenital Heart disease cardiologist / Cardiac imaging specialist/ Cardiac pathlogist. Patients with multiple comorbidities will frequently need to consult subspeciality colleagues, 1) Nephrologist , Endocrinologist, pulmonologist ,hematologist & gastro-enterologist 2) Oncologist, Obstetrician, Psychiatrist, Sleep medicine physician, geriatricians & palliative care providers , General surgery and others. Develop partnership with relevant subspecialties
- 20. LHFS HF patients need access to certain services ,in addition to medical and surgical subspecialties. Several resources and services are also included, 1) Electrocardiography ( EKG ) 2) Echocardiography 3) Cardiac magnetic resonance imaging ( CMRI ) 4) Cardiac stress testing & Cardio-pulmonary exercise testing ( CPET ). 5) Cardiac Cath, Coronary angiography ,and coronary and valve intervention. 6) Cardiac Rehabilitation 7) Palliative Care 8) Home nursing care 9) Infusion center / with in clinic , for OPD I/V diuretics and inotropes ( SDHFC ) Develop partnership with frequently used clinical services
- 21. LHFS Develop technology and Virtual visit infrastructure Advances in information technology and virtual visits , our compensated heart failure patients living in remote areas can benefit through telecommunication . This was especially relevant during COVID -19 pandemic , where many centers had adopted virtual visits for most of the heart failure patients in efforts to reduce exposure and transmission of infection. This opportunity taught us many things ,like 60% of our compensated patients in Makkah heart failure registry ,many of them can be followed in permanent “ Virtual HF Clinic “ in our MDHFP model of care. Develop technology and Virtual visit infrastructure
- 22. LHFS Develop technology and Virtual visit infrastructure Tele-medicine programs generally include some form of telecommunication between patients and care providers. It includes objective data acquisition ,such as vital signs, weight and activity monitoring and last not the least medication adherence. This telemedicine based intervention on mortality, hospitalization and quality of life end points , Variable results can be used across clinical trials . Some heart failure clinics in collaboration with electrophysiologist , may be able to have infrastructure and staff to monitor data from implanted devices including wireless pulmonary artery pressure sensor. Therefore these technologies may assist HF clinics in helping patients to spend more time safely at home and less time for monitoring in hospital setting. Many heart failure clinics, particularly EMR software clinical and administrative champions ( Super-users) can drive optimization of electronic medical record in the context of HF clinic workflows. Develop technology and Virtual visit infrastructure
- 23. LHFS Establish a mechanism for patient follow-up Once a patient has established care in multidisciplinary HF programme, it will be important to determine appropriate follow up intervals. 1) Who should be disposed from MDHFP, Heart failure with recovered LV ejection fraction EF > 40% , normal BNP level and absence of HF symptoms . 2)HF with improved EF > 40%, but still dilated LV with MR and pulm hypertension, raised BNP and symptomatic ,should have continue follow up in MDHFP. 3) Heart failure with uncertain prognosis living away from MDHFP ,can have “ shared care “ in which patient will have follow up with community HF / or with referring physician and have regular follow up at ( 4-6 months ) MDHFP physician /Virtual visit to save appointments, travel time at the cost to maintain patient confidence and relationship. Establish a mechanism for patient follow-up
- 24. LHFS Establish a mechanism for patient follow-up 4) Stable /compensated HF patients ,who are asymptomatic or minimally symptomatic can be seen annually to ensure they are receiving optimal doses of GDMT and are adhering to their medication regimen. Regardless of an in-person or virtual visit strategy, with periodic labs monitoring ( Renal profile and electrolytes) 5) Post discharge heart failure follow up ( PDHFC ). All heart failure patients ( De-novo /or ADCHF/& advanced HF ) are vulnerable for readmission with in 60 days , HF nurse co-ordinator should call them by phone on 3rd day of discharge if they are OK and no questions , book them for follow up appointment with in 7- 14 days after discharge. Establish a mechanism for patient follow-up
- 25. LHFS Establish a mechanism for patient follow-up 6 ) Same day Clinic without appointment ( SDHFC ) This is a flexible clinic for complex patients who require frequent follow up under special circumstances ,like those were seen in emergency department with new onset heart failure and left DAMA or refused admission or discharged after observation from Observation unit , they should have alternative to complete diagnostic work up or continuation of care and implementation and dose titration of GDMT . Those in transitional phase of advanced heart failure who require I/V diuretic or inotropic support can also be seen on this clinic to avoid visiting Emergency and recurrent hospitalization. 7) New onset HF with mild to moderate symptoms before confirmed diagnosis are also seen without appointment on rapid access HF clinic ( RAHFC ) Establish a mechanism for patient follow-up
- 26. LHFS Create a hospital coverage plan When patients are admitted first time to acute care hospital ,who are already enrolled in a programme , HF team is consulted to share in care during hospitalization . During transitional care from hospital to home , HF nurse will call patient on 3rd day ,if all goes smoothly then post discharge HF clinic is booked with in two weeks for continuation of care and follow up. Create a Hospital Coverage Plan
- 27. LHFS Determine a mechanism for continuous Quality improvement One of the most important aspect of maintaining a successful multidisciplinary heart failure programme is to ensure continuous quality improvement . Quality team should rigorously track objective clinical outcomes ,such as mortality and hospital admission. Additional quality measures may include, *Time from external referral to being seen.* GDMT use and appropriate dose titration. * Referral for ICD & CRT * Patient satisfaction * Care provider and staff satisfaction * Post discharge phone on 3rd day * Post discharge early ( 7-14 days ) follow up appointment before discharge* Phone call /electronic communication those who miss appointment to prevent lost follow up.* HF education delivered ,including patient teach-back and material handouts in local language. Determine a mechanism for continuous Quality improvement
- 28. LHFS Performance Measures for Heart Failure 1) LV ejection fraction assessment 2) Symptom and activity assessment 3) Symptom management 4) Beta-blocker therapy for HFrEF 5) ACE/ARB/ARNI therapy for HFrEF 6) ARNI therapy for HFrEF 7) Dose of beta-blocker therapy for HFrEF 8) Dose of ACE,ARB or ARNI therapy for HFrEF 9) MRA therapy for HFrEF 10) Laboratory monitoring for new therapy. 11) Hydralzine/nitrates those can not tolerate ACE. 12) Counseling regarding ICD implant for HFrEF on GDMT 13) CRT implantation for HFrEF on GDMT 1) NYHA functional classification assessment with in last 12 months. 2) HF activity recommendation provided. 3) Discussion of advanced directive/ care planning 4) Advanced directive executed 5) Beta blocker therapy for LV systolic dysfunction 6) ACE/ARB or ARNI for LV systolic dysfunction 7) MRA for LV systolic dysfunction JCI/ American Heart Association advanced Certification in HF 2020 ACC/AHA clinical performance & Quality measures in Heart Failure . Performance Measures for Heart Failure
- 29. LHFS Obtain Appropriate Accreditation Several organizations accredit heart failure clinics and multidisciplinary programmes like, clinical care programme certification (CCPC ) ,including joint commission ( JCI ) the ACC and AHA. PSCCH Al-ahssa was/is the only one CCPC ,HF center in middle east accredited in October 2017.( I had a honour to be co-ordinator of this specialized HF programme to win the certification ) CCPC heart failure need , adhere to standards in domains such as MDHFP and information management ,clinical care delivery, self- management education, and continuous quality improvement using standardized performance measures. We can contact those respective organizations to initiate the accreditation process. Obtain Appropriate Accreditation
- 30. LHFS Build a research Network Randomized clinical trials are foundation of evidence based medicine but have become increasingly difficult in research world. Physician scientist especially clinical investigators have been disappearing breed which is a disturbing trend. Although direct benefit of research participation extends to both patients and clinicians. With the establishment of HF programme ,and Makkah heart failure registry ,we can promote research awareness and access amongst young clinicians and HF patients indeed. To overcome barriers ,we should develop or join existing research network. Build Research Work
- 31. LHFS Develop a Business Plan A crucial step in developing a new multidisciplinary HF programme is constructing a business plan to support the network of specialized clinic and its goals. It is worthwhile to consider high-level topics that should be addressed in a concise business plan, they include 1) Executive summary, in local & plain language to discuss burden of heart failure in Larkana and in context of fractured health care delivery system. 2) Financial plan that includes projected MDHFP ,the volume of HF patients and revenue ,as well as expenses including those arising from requisite staffing. 3) Specific market analysis that highlights the clinical burden and business opportunity presented by network of HF clinics. Develop Business Plan
- 32. LHFS Develop a Business Plan Plan for capture of “ downstream “ business and savings generated by multidisciplinary heart failure program( MDHFP ) include, 1) Potential reduction in ist admission and readmissions rates associated with opening of rapid access HF clinics ( RAHFC ) and post discharge HF clinics ( PDHFC ) especially in vulnerable patients in vulnerable phase ( 60 days) . 2) Increase in procedures like, Cardiac cath-angio and intervention, cardiac surgeries , Echo, CPET, CMRI & others in right patients at right time. 3)Inter-hospital referrals of advanced HF patients for LVAD and heart transplant. Develop Business Plan
- 33. LHFS Conclusions 1) Heart failure continues to be associated with high rates of mortality and recurrent , prolonged hospitalization, which will have considerable burden on all HF stakeholders. 2) The comprehensive multidisciplinary HF programme and clinic network across Sindh healthcare cluster will significantly improve quality of outpatient heart failure care. 3) Going forward, MDHFP & network can serve in the role of a “ hub “ as advances in technology enable care to be shifted from inpatient to ambulatory outpatient ( like, I/V diuretic use in SDHFC ) 4) To improve quality of care and outcomes ,we need to focus on heart failure education amongst all stakeholders and heart failure research indeed. Conclusion
- 34. Conclusion “ Zigzag/Disorganized ” In Heart Failure world ,we are facing with these Tiger ( Small , non dilated & dysfunctional LV ) and Elephant ( Large ,dilated & dysfunctional LV ) hearts with heterogeneous prognosis. We spent tons of money on of heart failure care ,yet our services are Zigzag and fragmented. We need to review our problems, and work on organized care of heart failure for better outcome.
- 36. LHFS Refrences 1. CW, Carson AP, et al. Heart disease and stroke statistics-2019update:areport from the American Heart AssociationCirculation2019;139:e56 e528. 2. Heidenreich PA, Albert NM, Allen LA, Bluemke DA, Butler J, Fonarow GC, et al. Forecasting the impact of heart failure in the United States: a policy statement from the American Heart Association. Circ Heart Fail 2013;6:606–19. 3. Braunstein JB, Anderson GF, Gerstenblith G, Weller W, Niefeld M, Herbert R, et al. Noncardiac comorbidity increases preventable hospitalizations and mortality among Medicare beneficiaries with chronic heart failure. J Am Coll 4. Cardiol 2003;42:1226–334. Stewart S, Riegel B, Boyd C, Thompson DR, Burrell LM,Carrington MJ, et al. Establishing a pragmatic framework to optimise health outcomes in heart failure and multimorbidity (ARISE-HF): a multidisciplinary position statement. Int J Cardiol 2016;212:1–10. 5. Mentz RJ, Kelly JP, von Lueder TG, Voors AA, Lam CS, Cowie MR, et al. Noncardiac comorbidities in heart failure with reduced versus preserved ejection fraction. J Am Coll Cardiol 2014;64:2281–93. 6. Kociol RD, Peterson ED, Hammill BG, Flynn KE, Heidenreich PA, Pi~na IL, et al. National survey of hospital strategies to reduce heart failure readmissions: findings from the Get With the Guidelines-Heart Failure registry. Circ Heart Fail 2012;5:680–7. 7. Bradley EH, Curry L, Horwitz LI, Sipsma H, Wang Y,Walsh MN, et al. Hospital strategies associated with 30-day readmission rates for patients with heart failure. Circ CardiovascQual Outcomes 2013;6:444–50. 8. Hauptman PJ, Rich MW, Heidenreich PA, Chin J, Cummings N, Dunlap ME, et al. The heart failure clinic: a consensus statement of the Heart Failure Society of America. JCard Fail 2008;14:801–15. Refrences
- 37. THANK YOU Living Longer, Living Well