National Heart Failure
Audit Newsletter
Issue 7, November 2013
Introduction
It’s been a while since the last newsletter, so sorry for the delay. There’s been lots going on in the National Heart
Failure Audit, including the publication of the 2012/13 annual report, the finalisation of the 2014 dataset revision,
and the on-going web development.
This month’s newsletter includes a new ‘sharing good practice’ feature, written by one of the audit’s new HFNS
representatives, Kathy Simmonds from Kettering General Hospital. I hope that her comments on the data
collection process used in Kettering are useful, and that she inspires more of you to write in with your own
examples of good practice. The best ones will be published in the annual report next year!
The purpose of this newsletter is to provide regular communication to keep local users of the audit up-to-date with
audit developments and events. Please get in touch is there’s anything you would like to be included in the next
newsletter. Contact details are on page .
I hope to see many of you at the BSH autumn meeting tomorrow—come over and say hello!
2012/13 Annual Report published
The 2012/13 Annual Report was published on 21
November 2013.
For the first time, the report recorded a fall in mortality
rates, both in hospital and following discharge,
compared to last year. This is despite a patient group
with very similar characteristic, and seems to be
explained by an increase in the number of patients
receiving specialist care, which increases their chances
of receiving the recommended medications and being
referred for specialist follow-up care.
Despite this improvement, the report showed that there
is still variation in care depending on ward of treatment,
and also between hospitals. This has a significant
impact on outcomes.
For example, if a patient is treated on a cardiology ward
the likelihood of survival to discharge is far greater than
if a patient is admitted to other wards – in 2012/13 only
7.0% died if admitted to a cardiology ward compared to
11.3% on general medical wards and 14.4% on other
wards.
Patients who are treated on cardiology wards, or who
have specialist input into their treatment, are far more
likely to receive the recommended medications on
discharge and appropriate follow-up care. Although only
half of all patients were treated on a cardiology ward,
78% were seen by a nurse or doctor with a heart failure
specialism. This is not a bad figure, but there’s obviously
room for improvement.
We now have 97% of Trusts and 100% of Health Boards
participating—that’s just five Trusts in England which
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Also in this issue...
Updates on data definitions……….….….….2
Sharing best practice: data collection...…....3
Minimum data standard…………….…..…....3
2014 dataset revision………………..….…...4
Web application development.…….…..…....4
Multi-value fields……………………………...4
Changes to contact details…………………..5
Christmas closures…….……………..……...5
didn’t submit data in 2012/13. Of these five, all but one
have now registered with the NICOR helpdesk, so we’re
well on the way to 100%. Good work!
We also collected data on 43,894 admissions, which is a
substantial increase from last year.
Thank you to everyone who is involved in collecting and
submitting data to the audit—we couldn’t do it without
you! Huge thanks also to everyone who helped write,
edit and put together the report.
You can access the report on the NICOR website, and
the hospital level data is available to download on
data.gov.uk:
Report: www.ucl.ac.uk/nicor/audits/heartfailure/
additionalfiles
Hospital level data: http://data.gov.uk/dataset/
nationalheartfailureaudit2012-13
Issue 7
National Heart Failure Audit Newsletter
Updates on data definitions
Information about data definitions is provided below, particularly where multiple people have been in touch with
queries. If there are any data items about which you would like clarification, please contact Polly Mitchell (contact
details on p.5).

Discharge medication
There have been a couple of queries about the use of the ‘No’, ‘Not indicated’ and ‘Contraindicated’ options
in the discharge medication fields:
 No: the therapy was indicated for this patient, but they were not given it.
 Not applicable: the therapy was not clinically indicated for the patient.
 Drug therapy stopped: the patient had a prescription for the medicine when they were admitted to hospital,
but it was stopped during their admission.
 Contraindicated: there is a genuine contraindication meaning that the patient cannot tolerate the medicine,
e.g. low arterial pressure, hyperkalaemia or renal dysfunction for ACE inhibitor or bradycardia, intolerable
fatigue or asthma for beta blockers.
 Declined by patient: the therapy was offered to the patient, but they refused to take it, in spite of no
genuine contraindication.

Diagnosis of heart failure
The diagnosis of heart failure field should be used to record when a patient has been given a coded
diagnosis of heart failure on discharge (i.e. they meet the audit inclusion criteria), but has not been given a
clinical diagnosis of heart failure. In annual reports, patients who have this field recorded as ‘no’ and who also
have a normal echo and no symptoms or signs of heart failure are excluded from analysis. This field helps us
to understand the extent of inaccurate clinical coding, and prevents us from inadvertently including patients
without heart failure in our analysis.
 No: A diagnosis of heart failure was excluded by imaging or by a cardiologist.
 Yes: The diagnosis of heart failure has been confirmed by imaging or BNP testing either during this
admission or at a previous time, or has been explicitly confirmed by a consultant cardiologist.
 Unknown: No information about imaging or BNP is available to support a diagnosis of heart failure.

Follow up
‘Yes’ can be selected for the following fields if the patient has been referred for follow up on discharge, even if
a date has not yet been arranged for the appointment:
 HF liaison service: Referred for follow up with a HFNS (either hospital- or community-based clinic).
 COTE/medical follow up: Referred for follow-up at a care of the elderly or general medical clinic.
 Cardiology follow up: Referred for follow up with a consultant cardiologist or cardiology SpR.
 GP follow up: Discharged to the care of a GP.
‘Yes’ should only be selected for the this field if a date has been set for a follow up appointment with a
member of the HF MDT at the point of discharge from hospital:
 Review appointment with HF MDT: A follow-up appointment with a member of the HF MDT was made
before the patient was discharged from hospital.
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Issue 7
National Heart Failure Audit Newsletter
Sharing good practice: Data collection
By Kathy Simmonds, HFNS representative on the
National Heart Failure Audit Project Board
The project board acknowledges the commitment and
time required for Trusts to achieve the target case ascertainment. The dataset is being reviewed with a number of fields becoming mandatory in 2013/14 and a
move towards collecting data prospectively rather than
retrospectively. Developing systems to capture data that
are efficient and streamlined is always a challenge.
Sharing good systems and methods of data collection is
always helpful, particularly when the overarching goal of
the audit is to improve services and essentially the outcomes for our patients.
Increasing numbers of acute Trusts are employing
HFNS to be an integral part of the HF service and most
data collection is undertaken by the HFNS with or without admin support for data entry. One example of processes for data collection at a DGH is given as an example:
basis the HF nurse attends a 30 minute MDT meeting
on the cardiology ward where besides other information
potential discharges are identified. Data from current
patient notes can easily be gathered to capture the latest HR, BP and weight measurements plus ECG and
echo of those potential discharges identified. Medical
management and follow up arrangements are usually
captured remotely through electronic access to discharge summaries and path results. This process avoids
having to pull case notes retrospectively.
No system is fool-proof and, for patients who end up
being cared for in general medicine/COTE wards, the
HF Nurse is dependent on the wards informing them
when HF patients are due to be discharged. Anomalies
with the HES data continue to be an issue and development of rapport between coding and those collating the
NFHA data are useful.
Contribute your own examples of good practice
The HF nurse visits the admission wards on a daily basis to identify patients admitted with HF and to begin the
data collection on a local single page pro forma. These
patients are signposted to cardiology as appropriate and
are tracked through their inpatient journey. On a daily
We have a window of opportunity in the next few
months, before the start of the 2014/15 audit year, to
share examples of good practice. If your local systems
for case ascertainment have innovative, time saving
methods, or you have efficient ways of collecting, validating or submitting data that you are willing to share,
please email Polly Mitchell with a brief description
(contact details on p.5).
Minimum data standard
of records meeting this standard.
NICOR has asked for all of its audits to define a minimum data standard which all of the hospitals submitting
data to the audit must meet. This will have two parts: a
case ascertainment target and a data completeness target, and will be used as a measure of participation from
April 2014 onwards.
Therefore, we have decided that the data completeness
standard will be for 70% of records to have all of the
mandatory fields completed, with no ‘unknowns’, for the
2014/15 audit cycle.
The National Heart Failure Audit already has a case ascertainment standard—in 2013/14 we will accept 70% of
HES/PEDW recorded heart failure discharges as a minimum for a Trusts to count as participating. This standard
will carry over to 2014/15.
The Project Board has decided that the data completeness standard will focus on improving the number of
patients with 100% data completeness for mandatory
fields. In 2012/13 there were around 40% of records
which had a level of data completeness that was adequate for inclusion in the regression models in the annual report. Records must have all risk fields completed for
inclusion in the regression models. As we start to work
towards hospital-level risk adjustment, and publication of
mortality by hospital, it’s key that we push up the number
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For 2013/14, in order to get you used to the data completeness requirement, we will be aiming to reach 50%
of records achieving this standard of data completeness,
and will record in the next annual report whether each
hospital achieved this target. It will not, however, be a
strict requirement of participation until 2014/15.
As soon as possible we will also be including a data
completeness online reporting tool on Lotus Notes and
the new HF Web application, which will allow you to
check whether you are meeting the required standard of
data completeness throughout the year.
Having complete and clinically accurate data will enable
you to use the audit as a quality improvement tool to
effectively monitor the heart failure patients admitted to
your hospital.
Issue 7
National Heart Failure Audit Newsletter
2014 dataset revision
At the end of October a draft version of a revised dataset, which will be effective from 1 April 2014, was sent
out for review.
Thank you for all of your comments and suggestions on
the draft, a series of which were included in the final version. There were many good suggestions which we were
unfortunately not able to include—this revision of the
dataset focused on cutting down on collecting information that is not strictly necessary for the purpose of
audit. There are many data items that would be extremely interesting to collect for research purposes, but which
would constitute too much of a burden to include in the
audit dataset.
Remember that there are 30 ‘user defined fields’ that
you can use to record any information that is not already
captured by the audit.
The final revised dataset can be found on the NICOR
website here:
During April and May the two datasets will run in parallel.
When you create a new admission record you will be
able to choose which audit year the admission falls in. If
you import data to the database via csv files, the import
process will automatically detect which dataset you are
using, based on the number of fields in the csv file.
There are six months from now until the beginning of
June to make any necessary changes—we hope this
gives you enough time to adapt your current data collection tools.
Please make sure you familiarise yourself with the new
dataset before April, and if you have a locally developed
database from which data is exported to the audit, ensure that it is updated and tested by the beginning of the
2014/15 audit year.
Data entry pro formas are available for download on the
NICOR website (link as before) - there is a core pro forma, which only the fields that you are required to fill in,
and a full pro forma which covers all of the data items in
the dataset.
http://www.ucl.ac.uk/nicor/audits/heartfailure/dataset
The current dataset (version 3) should be used for all
patients discharged up until 31 March 2014. The new
dataset (version 4.2) should be used for all patients discharged from 1 April 2014 onwards. Note that the data
entry deadline for 2013/14 will be 2 June 2014. Version
3 of the dataset will be available until 2 June, and will
cease to function after this date.
Web application development
The development of a web-based version of the audit
application is well under way, and user testing is due to
start next week. When it’s ready for the official roll out
(within the next two weeks), you will receive an email
with instructions for obtaining access.
Phase 1 of the web-based application will be available
for direct data entry only, and will not have an import
facility. All data entered on the web will be accessible on
Lotus Notes and vice versa. You will be able to export
data from the web portal, and view the online reporting
tools. Any changes that you make in either tool will be
immediately visible in the other application.
We recommend that you maintain Lotus Notes access
for the time being, until the web application has identical
functionality to the existing audit tool. The web-based
application will allow you to access the audit from any
computer in your hospital with internet access, rather
than just on the computers with Lotus Notes installed,
which should facilitate timely data entry.
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Multi-value fields
There are three multi-value fields in the core dataset,
which allow you to record more than one answer to a
given question. There is some evidence that the fields
are often only being used to be record one value, and as
a result, certain information is being under-reported.
In particular it has been noticed that LBBB and previous
MI appear to be under-reported in the ECG field, with
only sinus rhythm and AF being recorded on the whole.
Furthermore, some sites have only recorded one of consultant cardiologist and HFNS in the field which records
which specialists the patient was seen by during their
admission.
Please make sure that you fully complete these fields,
including all relevant information.
Issue 7
National Heart Failure Audit Newsletter
Changes to contact details
Christmas closures
Please continue to keep us updated of any changes
to the contact details of those people involved with the
audit, so that we can keep you informed of changes to
the database and important updates relating to the
audit .
It’s still a little way off, but an advance warning that
UCL will be closed for a few days over the Christmas
period:
If someone with access to the National Heart Failure
Audit database leaves the Trust, goes on maternity
leave or is no longer responsible for the audit, the
name on the Lotus Notes licence and ID file will need
to be changed.
Please contact Polly Mitchell and the NICOR
helpdesk in the instance of any changes to database
users or contact details.
The NICOR helpdesk will be closed from 5pm on 20
December, and will reopen again at 9am on 2
January.
Polly’s last day in the office will also be 20 December,
and she’ll be returning to work on 6 January.
If you have any questions or need to get in touch over
the next month, please make sure you do so before
the 20 December!
Contact the audit
General enquiries
Contact Polly Mitchell, the National Heart Failure Audit project manager, with any clinical queries,
general questions about the audit or regarding any of the articles in this newsletter.
Email: polly.mitchell@ucl.ac.uk
Tel: 0203 108 3927
Technical enquiries
For any technical questions, problems using Lotus Notes or importing data, please contact the NICOR
helpdesk.
Email: nicor-helpdesk@ucl.ac.uk
Tel: 0203 108 1978
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Issue 7