Furness Heart Failure Service Model
Patient presents to GP with symptoms of Heart Failure
History (high risk if previous MI)
Clinical examination & relevant investigations - 12 lead ECG,
urinanalysis, bloods - U&Es, TFT, LFT, FBC, lipids and NTPro-BNP
(High >2000pg/ml; raised 400 -2000pg/ml; norm <400pg/ml) (QS2)
Acute heart failure
admission to hospital
(QS10, QS11, QS12)
Echocardiography (QS1, QS3, QS4)
History MI & or NTpro-BNP > 2000pg/ml refer for urgent
echo - within 2 weeks
NTpro-BNP 400-2000pg/ml within 6 wks
Confirmed Heart Failure Diagnosis –
LVSD / HFPEF
Initial heart failure managemant plan
(QS
Patient consents to HF referral
Referred to Heart Failure Service
Implement and review management plan
Heart Failure Nurse Practiitoner
(HFNP) follow up
Initial telephone / ward or clinic contact
(within 2 working days of referral)
1st Asessment either clinic /or home
visit (within 2 weeks for urgent
referral or hospital discharge)
Continued follow-up consultations
dependant on clinical need (2-8 week)
though HF clinic, telephone
consultations & home visits
Assess for cardiac rehabilitation (QS8)
Assess palliative care needs (QS13)
Assess for referral to cardiology
Discharge back to primary care once
HF is stable.
Discharge criteria:
HF is stable
Patient has completed self
management program
Patient is optimised on HF medication
Patients to be reviewed at least 6 monthly
by primary care (renal function and
medication review) (QS9).
GP HF Register
Copy of Management Plan
Box 1 - Responsibilities (QS5,QS6, QS7)
Undertake full comprehensive clinical assessment
Assess patient’s HF knowledge & understanding
Explain diagnosis & monitor HF knowledge
Review relevant blood results & investigations
Clinically examination
Heart rate (rate and rhythm, heart
sounds), BP & Resps.
Oedema, fluid overload, weight
JVP assessment
Chest examination
Tritrate medication to optimum dose in line with
NICE guidance & Furness HF pathway →
discuss variance with GP & at MDT
Provide single point of contact for team.
Amend HF management plan to meet individual
patients needs and copy to GP
Develop health literacy, empowerment &
encourage self management and concordance
Promote lifestyle change and risk awareness
Weight monitoring and fluid intake
Reduce Salt/Sodium intake and promote
healthy heart diet
Encorage paced activity & exercise
Smoking cessation advice
Social support and well being
Provide credible patient held information
Collaborative working with Community nurses
Offer joint consultation prior to discharge.
Continued professional support & advice.
Referral to cardiac rehab team.
Key: Colour depicts responsibilities taken from NICE (2010) key quality standards (QS)
Primary care
Secondary/Tertiary care
Specialist HF team
AP/LC 02. 2012
Furness Heart Failure Service Model
Referral criteria
 Newly diagnosed patients with echo confirmed left ventricular heart failure
 Patients discharged from secondary care with an episode of decompensated heart failure
 Patient must have confirmed left ventricular failure (code G581), either left ventricular
systolic dysfunction, LVSD (G5yy9) or left ventricular diastolic dysfunction now known as
heart failure preserved ejection fraction, HFPEF (G5yyA).
 Patient is aware and has consented to referral.
 Patient must have had symptoms of heart failure and /or not be on optimum heart failure
therapy.
 Patient or their carer must be able to participate in self management education.
 Patients registered with Furness GP or patients who are not register with a GP yet live
within Furness locality.
Referral process – completed referral forms:
 May be sent electronically to the service email (contact PRISM dept for technical queries
in primary care).
 Printed and faxed to the Heart Failure Team along with latest ECG and echo report
(minimum of date of echo report).
 Secondary and tertiary care referrals can be faxed, sent electronically or posted.
Point of Contact
 Furness Heart Failure Service
Base: 2 Fairfield Lane, Barrow- in- Furness, LA13 9AH
Tel: 01229 402575 Fax: 01229 402569
Service Email: HeartFailureTeam@cumbria.nhs.uk
Confirmation of referral
 The GP and referrer will receive written confirmation patient accepted on to HF service
caseload.
 The patient will be contacted by telephone within two working days.
On going monitoring:
 Patients will be expected to have their Heart Failure monitoring shared between their GP
surgery and the heart failure team. With the Practice Nurse (D/N for house bound
patients) taking patient bloods pre & post titration ACEi /ARB & Spironolactone and
checking HR & BP (7-10 days post titration). HR and when advised, 12 lead ECG pre &
post titration beta blocker (7-10 days post titration).
 The patient & their GP will have written notified of any medication changes same day re
titration form
 GP will receive a consultation letter within week of clinic appointment.
 All blood results will be returned to the GP as primary clinician.
 Patients who are have their heart failure medication management adjusted by the nurse
practitioners will have their bloods results monitored remotely by heart failure service in
line with (NICE, 2010).
Discharge from heart failure service:
 Stable patient and/ or on optimised HF therapy will be referred back to primary care.
 Where they should receive a clinical assessment at least every 6 months, including in this
is measurement of renal function and medication review (NICE,2010)
 Patient, GP and Consultant will get a letter confirming discharge from the heart failure
service.
 Re referral / self referral / will be accepted for changes in heart failure status.
AP/LC 02. 2012