Identifying if patient's living with heart failure retain knowledge better by gaining it through lived experience rather than through education

Funding Acknowledgements

Type of funding sources: None.

Background

Self-care is when a patient possesses a set of knowledge and skills that are used to process information to make correct health decisions. Self-care in heart failure (HF) includes monitoring symptoms for deterioration in HF and having an appropriate response time in contacting their health care provider. One of the main principles of a heart failure clinic is to provide a structured education programme for the patient regarding self-care. Patient education is the leading intervention to equip patients with the skills for symptom recognition. The education aims to ensure the patient can recall the knowledge from memory if required.

Purpose

The aim of this study was to evaluate patient knowledge, through testing memory, regarding symptom recognition in a single center HF clinic. To identify if there was a difference between attaining knowledge on symptom recognition gained through lived experience versus knowledge on symptom recognition gained through education.

Methods

50 patients were recruited for this study.

Average age was 72 years old.

38 male and 12 female.

All participants had previously experienced at least one symptom of HF.

All participants had a minimum of 2 education sessions in the HF clinic.

All patients had evidence from their weight logbook of daily weight monitoring. Question "a" tests knowledge acquired from education and question "b" tests knowledge acquired from lived experience.

All participants were asked two questions:

a) what is the amount of weight increase you are monitoring for?

b) name one symptom you are monitoring that would indicate possible deterioration in HF.

Results

single center prospective analysis

Question a: 35% answered correctly

Question b: 82% answered correctly

Conclusions

Processes of learning and the transfer of learning are central to understanding how people can achieve competency in self-care. In this study patients seem to remember information better from a lived experience rather than trying to recall taught information. It important to identify the patients’ individual factors and needs to successfully support their self-care management. Further evaluation of assessing the implementation of other supports available such as, mobile Apps and multimedia-based education, to address knowledge recall deficits is needed to determine if they aid the patient to achieve competency in self-care.

Illuminating the need for a specific clinical care pathway for patients living with heart failure and identified as clinically frail

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Against a background of increasing global population aging, frailty affects 8-10% of those over 65 years and 25-50% in those over 85 years. Frailty has a 4-6 times greater prevalence in heart failure patients and is increasingly recognised as a predictor of increasing hospitalisation and mortality in cardiovascular disease. The Rockwood Clinical Frailty Scale estimates an individual’s degree of frailty on a scale of 1(very fit) to 9 (terminally ill) with a score of 5 or greater indicating frailty.

Purpose

To estimate the 30-day prevalence of frailty in patients attending an ANP-led Heart Failure Clinic as a precursor to developing a clinical care pathway that systematically identifies frailty and triggers a comprehensive geriatric assessment.

Methods

A multi-centre audit was conducted in three hospitals in Ireland. We retrospectively audited consecutive patients attending three ANP-led HF clinics in November 2021 to assess the prevalence of frailty. Demographic data, NYHA classification, number of hospital admissions in the previous year, clinical Frailty Score (CFS) and the number of patients under the care of a geriatrician was obtained from the medical notes of 170 heart failure patients consecutively reviewed. CFS was calculated in those patients over 65 years.

Results

Of 376 HF reviews in November 2021, 170 individual patients were identified, 65% were male, 86% were aged 65ys or older of which 34% were over 80 years and a mean age of 73.4 years. 52% of the cohort were admitted at least once in the previous year of which 12% were admitted twice and 5% were admitted 3-4 times. 37% were classified as NYHA III and 0.6% were NYHA IV. The majority (68%) were newly diagnosed with HF within the previous year. 14% of patients were aged under 65yrs and did not have a CFS, 19% were deemed vulnerable (CFS 4), 41% were CFS 5 or greater and only 5% were under the care of a geriatrician.

Conclusion(s)

The prevalence of frailty (41%) was high in comparison with the national average of 24% and global average of 17%. Despite a strong association between age, frailty and heart failure, few patients were managed by a geriatrician. This audit emphasises the importance of developing a regional clinical care pathway that promptly recognises frailty in a high-risk population and triggers a comprehensive geriatric assessment. Furthermore, this audit highlights the limitations of the CFS in demonstrating cognitive and social vulnerability provoking further discourse in how patients are assessed and managed in the future.

Protection of bone mineral density in heart failure patients:audit on current clinical practice in a busy tertiary care hospital cardiology department in Ireland

Background

The strong association between heart failure (HF) and osteoporosis is well recognised. Heart failure, due to its multiple risk factors and common pathogenesis with osteoporosis can lead to low bone mineral density (BMD) and increase the risk of fragility fractures. The mortality of HF patients following these fractures is high. Current National Osteoporosis Foundation Guidelines recommend that pharmacological therapy should be reserved for postmenopausal women and men aged 50 years or older who present with a hip or vertebral fracture, where the vertebral fractures may be clinical or identified on a radiograph alone.

Methods

Most HF patients have frequent chest radiographs over their course years. We aimed to audit the prevalence of osteoporosis and current practice of prescribing BMD-protection in patients attending the HF clinic in a busy tertiary care hospital in Ireland. 100 patients attending the clinic in the last one year were randomly selected and clinical, medication and chest radiograph information on this cohort was collected via the hospital electronic information system. All those patients with Radiologist confirmed vertebral compression fractures (VCF) on their plain chest radiographs were audited regarding osteoporosis screening and bone protection prescription.

Results

Due to limited penetration,18 out of 100 chest radiographs were inconclusive,reducing the sample size to 82. 9 out of the remaining 82 patients had radiologist confirmed VCF on their plain chest radiographs whereas 2 patients had VCF incidentally picked up on their lumbar spine x-rays. All patients were aged more than 50. 4 were female and 7 male. Median ejection fraction calculated was 35%. 3 out of 11 were smokers,8 had atrial fibrillation and were on anticoagulation,4 had DM-II and 2 had CKD. 10 were on loop diuretics. Of note,4 patients were on calcium and vitamin D supplements but only 1 patient was on antiresorptive therapy for osteoporosis.

Conclusion

Despite its strong association with heart failure,Osteoporosis remains undertreated in this patient cohort.Due to the significant mortality and morbidity associated with major osteoporotic fractures, doctors should carefully assess and screen heart failure patients for osteoporosis and initiate specific therapy where indicated.

Funding Acknowledgement

Type of funding sources: None.

Heart Failure Patients with type II diabetes still require more focus

Funding Acknowledgements

Type of funding sources: None.

Background

A bidirectional relationship exists between heart failure and diabetes; heart failure is a risk factor for type II diabetes and type II diabetes is a risk factor for heart failure. The prevalence of both chronic conditions is on a continuous upward rise. Heart failure has a poorer prognosis than diabetes and therefore heart failure patients with diabetes should be also managed at a heart failure centre. It has been shown that heart failure medication is of benefit to patients with or without diabetes.

Purpose

With new advances in heart failure medication this retrospective and prospective analysis examines if patients with or without type II diabetes receiving similar care at a heart failure centre will have similar outcomes.

Methods

 A retrospective and prospective cohort analyses was performed on 50 patients attending a single centre heart failure clinic over a 12-month period. LVEF, NT Pro BNP and NYHA was examined pre- and post-receiving similar heart failure care.

Results

50 patients were recruited for this study. There were 25 patients in the type II diabetes cohort (10 female: 15 male. Average age 77 years old) and 25 patients in the non-diabetes cohort (7 female:18 male. Average age 79 years old). In the type II diabetes cohort average LVEF pre care 27%: post care 33% (difference 6%), average NT Pro BNP pre care 3558 pg/ml: post care 2564 pg/ml (difference 994 pg/ml), average NYHA pre care II: post care I-II (difference of 0.5).

In the non-diabetic cohort average LVEF pre care 26%: post care 37% (difference 11%), average NT Pro BNP pre care 1679 pg/ml: post care 1135 pg/ml (difference 544 pg/ml), average NYHA pre care II: post care I-II (difference 0.5).

Conclusion

Both cohorts of patients had similar NYHA functional class outcomes. The patients in the type II diabetes cohort had higher NT Pro BNP levels pre care and higher reduction in NT Pro BNP post care than the non-diabetic cohort. Both cohorts had similar LVEF pre care, but the non-diabetic cohort had better improvement post care, with possible avoidance of need for implantable cardiac devices compared to the type II diabetes cohort. This study shows that heart failure nurses should be aware that heart failure patients with type II diabetes carry a higher risk profile and should be actively identified as part of an individualised, person-centred care approach. Heart failure patients with type II diabetes need to have vigilant scrutiny of their care to optimise their outcomes.

Correlation of STOP-bang obstructive sleep apnoea screening tool to apnoea-hypopnea index in a general cardiology population

Funding Acknowledgements

Type of funding sources: None.

Introduction

The link between obstructive sleep apnoea (OSA) and cardiovascular disease is well known. Prevalence can be very high in this population, sharing many pathophysiological drivers in addition to being a risk factor. More concerning however is the increasing number of patients with undiagnosed OSA, who are at higher risk of long-term complications such as coronary artery disease, hypertension, atrial fibrillation, heart failure or stroke. There are several OSA screening tools available to clinicians, with variable sensitivities and specificities depending on patient demographics.

Predictive efficacy of the STOP-Bang screening tool in a general cardiology population with mixed cardiovascular disease has not been established.

Proposal

To identify the correlation between the STOP-Bang assessment score (1-8) and real-world Apnoea-Hypopnoea Index (AHI) in a general cardiology clinic population.

Methods

250 successive patients in a general cardiology clinic were asked to complete a STOP-Bang assessment. Of those, 50 patients with a variety of STOP-Bang scores were randomly selected to undergo sleep studies. A STOP-Bang value of ≥ 5 was taken as high-risk for moderate-severe OSA. Statistical linear regression analysis was performed in IBM SPSS version 26.

Results

Of n = 50 patients, mean STOP-Bang score =3.7 (SD +/-2.17) with mean AHI =15.8, (SD +/- 14.3). See Table 1 for categories 1-8. N = 44 (88%) had AHI ≥ 5 (At least mild OSA). N = 18 (36%) had an AHI ≥ 15 (Moderate-severe OSA). N = 29 (58%) had symptoms such as sleepiness, loud snoring or witnessed apnoea. Correlation between STOP-Bang score and AHI was high, with an  R value of 0.704, R2 = 0.496 (p < 0.01). A STOP-Bang score increase of 1 corresponded with a mean AHI rise of 4.648. When taking a STOP-Bang value of ≥ 5 as "positive", we demonstrated a sensitivity of 83.33% (95% C.I. 58.58-96.42) and specificity of 93.94% (95% C.I. 79.77-99.26%) for moderate-severe OSA (AHI ≥ 15). 

Conclusion

We discovered a very high number of patients with undiagnosed OSA of at least mild severity. We found a strong correlation between STOP-Bang score and real-world AHI in a general cardiology population with mixed cardiovascular disease with 5 as an acceptable screening score for moderate-severe OSA.

Table 1 STOP-Bang Value 1 2 3 4 5 6 7 8 Patients (N=) 12 5 7 9 5 5 5 2 AHI (Mean) 6.67 6.62 9.97 11.95 24.44 22.20 39.54 35.25 Standard Deviation (±) 3.29 2.74 3.45 4.63 12.87 5.69 27.2 6.72 Summary of mean apnoea-hypopnoea index and standard deviation for each STOP-Bang patient category.

Abstract Figure 1

Integrating intravenous frusemide treatment into the community for heart failure patients

Background

A structured pathway was developed to allow patients to safely receive intravenous (i/v) frusemide at home.

This pathway was implemented by an integrated team consisting of primary and tertiary care.

This allowed the traditional acute hospital treatment to be now delivered in the community.

Purpose

This concept has been used on an individual case basis by a minority of acute hospitals.

Previously there was no structured pathway that would allow this treatment to become a standard part of heart failure treatment by acute hospitals.

The pathway would ensure that the treatment would be delivered safely to a cohort of patients who meet certain criteria.

Methods

A pathway was developed by a consultant cardiologist, heart failure (HF) nurses and the Community Intervention Team (CIT)/CareDoc. The Caredoc Community Intervention Team (CIT) is a nurse led professional team that provides acute nursing care to patients in the community setting.

The HF nurse would identify the suitable patient for i/v frusemide as per pathway.

A referral would be sent to the CIT team who would administer the frusemide at the patients home.

The CIT team would take a renal profile daily, check vital signs, check symptoms of HF and check daily weight on the patient while they were receiving i/v frusemide.

The bloods results would be reviewed daily by the HF nurse.

The HF nurse would liaise daily with the CIT team and patient for symptoms, daily weights and vital signs. The patient would then be reviewed in the HF clinic post treatment.

Results

Single centre retrospective analysis was undertaken of the patients who received i/v frusemide at home over a 3 year period.

83 patients meet the inclusion criteria and received the treatment. 70 male and 13 female.

Average age 78 years old.

Average length of treatment 3 days.

Treatment was given twice daily, average daily dose was 137 mg. Majority of treatment was 80mg bd or 60 mg bd.

No failure cannulating any patient as CIT had high cannulation skills due to regular cannulation as part of workload.

3 episodes of hypokalaemia, lowest potassium was 3.1 mmols, all 3 episodes were effectively treated with oral potassium supplements.

No significant acute kidney injury was noted that required change to treatment.

6 patients required heart failure associated admission to hospital, 3 had hypotension, 1 has fast A-flutter and 2 remained resistance to i/v frusemide and required inotropes.

Both patient and carers reported a high satisfaction rate with the service.

Conclusion

National length of stay for a HF patient in Ireland is 11 days.This novel structured pathway successfully selected appropriate patients who can safely receive i/v frusemide at home. 93% avoided hospital admission.This reduces the need for acute hospital admission and significant associated costs. Patients and carers rated 95% satisfaction with service.Sustainability of the project is driven by an integration team approach.

Funding Acknowledgement

Type of funding source: None