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014 Specialist intervention leads to improved in-patient outcomes in patients with decompensated heart failure: impact of introducing a heart failure team
  1. J Masters,
  2. I Anton,
  3. J Szymanski,
  4. E Greenwood,
  5. J Grogono,
  6. D Kelly,
  7. P J Cowburn
  1. University Hospital Southampton, Hampshire, UK

Abstract

In the Health Care Commission Audit in 2005, our hospital had an in-patient (IP) mortality of 30%. A Heart Failure Team (HFT) was introduced to provide specialist in-patient care wherever the patients presented. The HFT was composed of two specialist nurses, a part time pharmacist and a clinical fellow and was led by a Consultant Cardiologist with a special interest in HF. The service commenced in April 2008. In the first year of the service 211 IPs were seen by the HFT. The mean age was 72.0 years (SD ±13.0), 40% were female, 53% had ischaemic heart disease and 28% were diabetic. Examination findings on admission revealed a mean heart rate of 89 (±26) bpm and a mean systolic BP of 126 (±25) mm Hg; mean QRS duration was 116 (±44) ms. 79% had an IP echo: of these 70% were classified as having moderate/severe left ventricular systolic dysfunction with 15% having preserved LV systolic function. Admission bloods revealed a mean Na of 135 (±6) mmol/l, urea 12 (±12) mmol/l, eGFR 51 (±22) and Hb 124 (±23) g/l. Mean length of stay (LOS) was 19 (±18) days. In the preceding 6 months 215 patients were coded with a primary diagnosis for HF. Subsequent case note review confirmed that 196 patients had been correctly coded. The baseline characteristics and outcome of these 196 patients are described. The mean age was 73.5 years (±14.7), 36% were female, 51% had ischaemic heart disease and 26% were diabetic. Examination findings on admission revealed a mean heart rate of 87 (±21) bpm and a mean systolic BP of 126 (±28) mm Hg; mean QRS duration was 117 (±37) ms. 82% had an IP echo: of these 63% were classified as moderate/severe left ventricular systolic dysfunction with 17% having preserved LV systolic function. Admission bloods revealed a mean Na of 135 (±6) mmol/l, urea 11 (±12) mmol/l, eGFR 48 (±23) and Hb 122 (±22) g/l. Mean LOS was 17(±19) days. All ns vs HFT baseline demographics. Despite very similar baseline characteristics and LOS, outcomes were very different. The IP mortality in the pre-HFT cohort was 23% whereas the patients managed by the HFT had an IP mortality of 6% (p<0.001). Analysis of discharge medications shows patients managed by the HFT received higher doses of loop diuretics (mean bumetanide/equivalent dose 2.4 (±1.5) mg HFT vs 1.6 (±1.2) mg pre HFT, p<0.001) with more receiving intravenous diuretics during hospitalisation (88% of HFT patients vs 76% pre-HFT, p=0.002). Discharge prescription of thiazide diuretics was also commoner in the HFT patients (17% vs 5%, p=0.001). ACE-inhibitors and/or ARBs (91% vs 83%, p<0.05) and aldosterone receptor antagonists (68% vs 44%, p<0.001) were prescribed more frequently by the HFT on discharge. β-blocker use was similar (HFT 63% vs pre-HFT 59%, ns). The introduction of a specialist HFT dramatically reduced in-patient mortality. Improved use of evidence based therapies, together with more aggressive diuretic use, may contribute to the difference in patient outcomes.

  • Heart failure
  • multidisciplinary care
  • diuretics

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