Volume 16 - Issue 2, 2016 - Cover Story

Designing a Hospital Cardiology Outreach Service

 

The cardiology team at Sheffield Teaching Hospitals NHS ‏Foundation Trust successfully designed and implemented ‏an outreach service for heart failure patients ‏in non-cardiology wards (National Institute for Health and ‏Care Excellence 2014a). The service was required as cardiologists ‏care for around 18-25 percent of heart failure patients, while ‏75-78 percent are under the care of non-cardiologists. In addition, ‏outreach is recommended in the UK National Institute for ‏Health and Care Excellence (NICE)’s acute heart failure guidelines ‏(NICE 2014b). HealthManagement.org spoke to consultant ‏cardiologist and service lead, Dr. Abdallah Al-Mohammad, ‏to find out more.

 

‏How were cardiac patients in ‏non-cardiac inpatient settings ‏treated before the heart failure ‏outreach service was set up?

 

Prior to the establishment of the ‏heart failure multidisciplinary team ‏meeting and ward rounds, patients ‏with heart failure admitted into non-cardiac beds were treated ‏by their physicians, who were attempting to follow the ‏guidelines while addressing the multiple co-morbidities that ‏these patients frequently have. However, not infrequently, the ‏majority of these patients (72-75 percent) were not receiving ‏evidence-based therapy mandated for those patients with ‏heart failure with reduced left ventricular ejection fraction ‏(HFREF). The chief reasons for the low uptake of these medications ‏were concerns about low blood pressure and abnormal ‏renal function in addition to remaining doubts amongst ‏some physicians about the wisdom of beta-blockers in certain ‏subgroups of patients with heart failure.

 

‏Why did you decide to set up a heart failure outreach service?

 

As a tertiary cardiac centre our specialist beds are in significantly ‏high demand, preventing us from accommodating all ‏patients with heart failure within ‏our bed complement. In addition, ‏I was dismayed by the very ‏low percentage of uptake of ‏therapies such as ACE inhibitors ‏and beta-blockers amongst the ‏patients with heart failure admitted ‏under the care of non-cardiologists ‏(these patients constitute ‏the majority of the patients with heart failure in our hospital). ‏I proposed that one could take cardiology expertise to these ‏patients without taking over their care. Thus, we provide these ‏patients with cardiology opinion and advice, while keeping ‏them under the care of their respective physicians, who are ‏best suited to look after their other co-morbid conditions.  ‏Thus we avoid using our tertiary centre cardiology beds for ‏those with heart failure who do not require non-pharmacological ‏cardiac interventions.

 

How did you set out to design this service? Who was involved?

 

I started by gathering support for the idea of the creation of ‏a new heart failure service within my departmental management ‏team. We then presented a paper outlining the aims of ‏the service to the hospital’s management team. The hospital’s ‏management set up a project that included two interested ‏cardiologists, three general physicians (one diabetologist ‏and two geriatricians), a nurse director, a nursing matron ‏and a manager. We set out the vision of the project based ‏on my suggestions, and then we were tasked with looking ‏into the steps needed to create the collaborative type of ‏service that could work across departmental borders, with ‏the aim to provide patients with heart failure who are under ‏the care of non-cardiologists with the cardiology expertise ‏needed to afford them the best evidence-based treatment ‏for their heart failure.

 

We concluded after a few months with a service design ‏that was agreed with the department of medicine and with ‏the hospital management before we started applying the ‏agreed changes. We appointed more heart failure specialist ‏nurses and trained the general medical nurses, who will ‏look after the majority of the patients. We tried to concentrate ‏the patients in a geographical area within the department ‏of medicine.

 

What did you perceive as the main barriers and challenges to setting up this service?

 

Physicians are naturally independent medical practitioners. ‏While they welcome the help of certain specialists when they ‏ask for that help, the model of our heart failure multidisciplinary ‏team dictates in addition to responding to referrals ‏from the physicians and the nurses in the general medical ‏ward that we also seek out potential patients with heart ‏failure even if not formally required to do so. In addition, our ‏participation included further involvement with and advice ‏provided to the patients and their caring nursing and medical ‏teams without necessarily being asked to do so. Winning ‏the trust of all these practitioners was at times difficult and ‏required patience and perseverance along with exercising ‏the utmost respect to the integrity and the independence ‏of the caring doctors and their teams.

 

The service significantly increased my personal workload ‏as I continued to provide general and specialist cardiology ‏care to my own patients. Subsequently I was able to demonstrate ‏that more help was needed to enable me to deliver ‏the service that expanded significantly over time. Now the ‏heart failure multidisciplinary team ward rounds are delivered ‏by four cardiologists (instead of just one - I was doing ‏this alone for a considerable length of time). We are about ‏to expand the team to five cardiologists.

 

What are the critical success factors for this service?

 

  • Collaboration and trust that was built with the physicians ‏delivering the care to the majority of the patients ‏with heart failure;
  • Team working environment with the nurses and the administrators as well as the managers in the heart failure service;
  • Continuing involvement of the managers and representatives of all those involved in a monthly meeting to manage any difficulties that may arise in the conduct of the service;
  • Perseverance and commitment by the heart failure nurses and the cardiologists with an interest in heart failure;
  • Creation of a learning environment for both the heart failure nurses and the junior cardiology staff attached to the team.

 

What makes for successful inter-departmental collaboration? How did you gain acceptance and get buy-in from other clinicians?

 

  • Proving to colleagues that all I needed was to simply help them better manage their patients’ conditions with no personal agenda beyond that;
  • Proving to colleagues that the involvement of the HF team had actually resulted in better therapeutic uptake and better outcomes for the patients;
  • Respecting everyone involved in the delivery of care for these patients as equal partners and avoidance of any implication that may be perceived as undermining their work or their authority;
  • Setting up an annual meeting for the service where ‏all those involved are invited to attend a review of the ‏achievements by the service and the difficulties faced or ‏perceived in order to openly discuss those and consider ‏solutions.


You increased staffing for this service after the initial setup. What factors make this service sustainable?

 

We monitor the performance of the service and the difficulties ‏encountered by the members of the team, and we ‏attempt to persuade the management that further increases ‏in the number of staff are genuinely required. We also work ‏with the management on ways to ensure the best efficiency ‏is achieved by the team prior to expansion as well as looking ‏at ways to make any increase in the staff justifiable and ‏paid for through improved direct or indirect productivity.

References:

National Institute for Health and Care Excellence (2014)

Acute heart failure: diagnosis and management. NICE guidelines CG 187. [Accessed: 3 May 2016] Available from nice.org.uk/guidance/cg187


Sheffield Teaching Hospitals NHS Foundation Trust (2014)

Sheffield's Heart Failure MDT (Outreach service into non-cardiology wards) NICE case study [Accessed: 3 May 2016] Available from nice.org.uk/

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Designing a Hospital Cardiology Outreach Service Designing a Hospital Cardiology Outreach Service for heart failure patients ‏in non-cardiology wards

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