CLINICAL AUDIT TOOL:
Heart Failure with
Left Ventricular
Systolic Dysfunction Non-Pharmacological
Management
Introduction
This clinical audit tool addresses the non-pharmacological management of heart failure with
left ventricular systolic dysfunction (LVEF <45%) in the primary care setting.
It draws on best practice guidance summarised in the New Zealand Primary Care Handbook
2102 on Heart Failure and specific content from the source guideline New Zealand Guideline
for the Management of Chronic Heart Failure (2009 update).
See http://www.health.govt.nz/publication/new-zealand-primary-care-handbook-2012 for
content in the Handbook and www.heartfoundation.org.nz for the full guideline.
TOPIC
Heart Failure with Left Ventricular Systolic
Dysfunction – Non-Pharmacological Management
Why is this topic of interest or concern?
 Patients with heart failure and left ventricular systolic dysfunction
are frequently managed in primary care. Non-pharmacological
management is an important component of their care.
Key points on non-pharmacological management from the guidance:

Observational studies support the relationship between smoking cessation
and decreased mortality and morbidity in patients with heart failure. An
ABC approach to smoking cessation should be used for all patients with
heart failure who smoke.

A comprehensive clinical assessment should be undertaken prior to
referral for/recommendation of an exercise programme. Exercise is an
important aspect of non-pharmacological management of heart failure for
many patients. However, there are some absolute and relative
contraindications to exercise training. See Table 5 (page 26) of the full
Guideline for details.

The Heart Foundation information booklet for patients Staying well with
heart failure has been prepared to complement the guideline. It is available
from www.heartfoundation.org.nz
2
PLAN
Indicators
(elements of practice performance to be measured)
The practice effectively provides non-pharmacological management for patients
with heart failure with LV systolic dysfunction
1.
Information and advice as appropriate to the individual is provided on:

heart failure, prognosis, management

dietary salt restriction

fluid and alcohol intake

physical activity

smoking cessation (using the ABC approach) if the patient is a current
smoker.
2.
A target weight range is identified and regular monitoring of weight by the
patient is discussed.
3.
Advice on symptom recognition is given and an action plan as to when the
patient should seek medical help for worsening symptoms (weight gain,
shortness of breath, peripheral oedema, or other symptoms) is discussed.
4.
Participation in an exercise programme is considered.
5.
Annual influenza vaccination and five-yearly pneumococcal vaccination is
considered.
Criteria
1.
(how the indicator will be measured)
Patient records indicate relevant information and advice has been given.
This may include provision of written information (e.g. Heart Foundation’s
Staying well with heart failure) or referral to heart failure nurse specialist
services.
Patient records indicate smoking cessation advice has been given if the
patient is a current smoker.
2.
Patient records indicate target weight range and planned approach to
monitoring of weight by the patient.
Patients should weigh themselves regularly, preferably daily and at the
same time of the day.
3.
Patient records indicate an action plan as to when the patient should seek
medical help for worsening symptoms (weight gain, shortness of breath,
peripheral oedema, or other symptoms) has been discussed.
4.
Participation in a home or community exercise programme or a
contraindication to exercise training is recorded in the patient records.
In general, patients who have stable cardiac symptoms and who are
receiving optimal heart failure therapy should be referred to an exercise
programme. Table 5 (page 26) of the full Guideline provides details of
absolute and relative contraindications. In those with relative
contraindications, a decision is required as to whether or not the benefits
of exercise training outweigh the risks.
3
5.
Patient management system ‘flags’ when annual influenza and five-yearly
pneumococcal vaccination is due for the patient. Alternatively, the patient
records indicate that vaccinations are contraindicated.
Standards
(the standards to be achieved)
Note that the focus is on improving standards of clinical practice, with 80%
achievement identified by the RNZCGP as an appropriate target and 100% as an
ideal. Individual GPs and practices may choose to set a differing target for a first or
subsequent audit/s, with a view to increasing standards over time.
1.
80% of patient records for patients with heart failure with LV systolic
dysfunction indicate relevant information and advice on heart failure and
self-management has been given.
80% of patient records for those who are current smokers indicate that
ABC smoking cessation advice has been given.
2.
80% of patient records note a target weight range for the patient and
indicate discussion on patient monitoring of weight.
3.
80% of patient records indicate an action plan in the event of worsening
symptoms has been discussed with the patient.
4.
80% of patient records indicate the patient’s suitability for an exercise
programme has been assessed.
5.
80% of patients have an annual influenza and pneumococcal vaccination
recall in the patient management system.
DO
Discover what you are doing now

(collect data)
Retrieve records for 15-20 random patients with heart failure and LV systolic
dysfunction.

Review patient records using copies of the Individual Patient Record Review
Sheet.
STUDY
Next steps: what do the results tell you (interpret the data)

Collate the data from patients according to the standards set and compile a
brief summary for each indicator.

What are you doing well?

What needs improving?

What gaps between standards and performance do you want to close?

Identify possible solutions.
4
Clinical Audit Tool: Heart Failure with Left Ventricular Systolic
Dysfunction: Non-Pharmacological Management
Patient Record Review Sheet
Date:
Patient 1 (add initials/NHI):
Information/ advice
Target weight
Action plan for
Suitability for
Recall for annual
provided on heart
range
patient
exercise
influenza &
failure and self-
recorded?
discussed in
programme
pneumococcal
event of
assessed?
vaccinations in PMS
Yes/No
Yes/No/Contraindicated
management?
Topics – prognosis,
Yes/No
management, dietary salt
symptoms?
restriction, fluid & alcohol
intake, physical activity
Yes/No/Don’t know
ABC smoking cessation
advice given?
Yes/No/NA
worsening
Yes/No
Patient
monitoring of
weight
discussed?
Yes/No/NA
Comments:
Patient 2 (add initials/NHI):
Information/ advice
Target weight
Action plan for
Suitability for
Recall for annual
provided on heart
range
patient
exercise
influenza &
failure and self-
recorded?
discussed in
programme
pneumococcal
event of
assessed?
vaccinations in PMS
Yes/No
Yes/No/Contraindicated
management?
Topics – prognosis,
Yes/No
management, dietary salt
symptoms?
restriction, fluid & alcohol
intake, physical activity
Yes/No/Don’t know
ABC smoking cessation
advice given?
Yes/No/NA
worsening
Yes/No
Patient
monitoring of
weight
discussed?
Yes/No/NA
Comments:
5
Patient 3 (add initials/NHI):
Information/ advice
Target weight
Action plan for
Suitability for
Recall for annual
provided on heart
range
patient
exercise
influenza &
failure and self-
recorded?
discussed in
programme
pneumococcal
event of
assessed?
vaccinations in PMS
Yes/No
Yes/No/Contraindicated
management?
Topics – prognosis,
Yes/No
management, dietary salt
symptoms?
restriction, fluid & alcohol
intake, physical activity
Yes/No/Don’t know
ABC smoking cessation
advice given?
Yes/No/NA
worsening
Yes/No
Patient
monitoring of
weight
discussed?
Yes/No/NA
Comments:
Patient 4 (add initials/NHI):
Information/ advice
Target weight
Action plan for
Suitability for
Recall for annual
provided on heart
range
patient
exercise
influenza &
failure and self-
recorded?
discussed in
programme
pneumococcal
event of
assessed?
vaccinations in PMS
Yes/No
Yes/No/Contraindicated
management?
Topics – prognosis,
Yes/No
management, dietary salt
symptoms?
restriction, fluid & alcohol
intake, physical activity
Yes/No/Don’t know
ABC smoking cessation
advice given?
Yes/No/NA
worsening
Yes/No
Patient
monitoring of
weight
discussed?
Yes/No/NA
Comments:
6
Patient 5 (add initials/NHI):
Information/ advice
Target weight
Action plan for
Suitability for
Recall for annual
provided on heart
range
patient
exercise
influenza &
failure and self-
recorded?
discussed in
programme
pneumococcal
event of
assessed?
vaccinations in PMS
Yes/No
Yes/No/Contraindicated
management?
Topics – prognosis,
Yes/No
management, dietary salt
symptoms?
restriction, fluid & alcohol
intake, physical activity
Yes/No/Don’t know
ABC smoking cessation
advice given?
Yes/No/NA
worsening
Yes/No
Patient
monitoring of
weight
discussed?
Yes/No/NA
Comments:
Patient 6 (add initials/NHI):
Information/ advice
Target weight
Action plan for
Suitability for
Recall for annual
provided on heart
range
patient
exercise
influenza &
failure and self-
recorded?
discussed in
programme
pneumococcal
event of
assessed?
vaccinations in PMS
Yes/No
Yes/No/Contraindicated
management?
Topics – prognosis,
Yes/No
management, dietary salt
symptoms?
restriction, fluid & alcohol
intake, physical activity
Yes/No/Don’t know
ABC smoking cessation
advice given?
Yes/No/NA
worsening
Yes/No
Patient
monitoring of
weight
discussed?
Yes/No/NA
Comments:
7
Patient 7 (add initials/NHI):
Information/ advice
Target weight
Action plan for
Suitability for
Recall for annual
provided on heart
range
patient
exercise
influenza &
failure and self-
recorded?
discussed in
programme
pneumococcal
event of
assessed?
vaccinations in PMS
Yes/No
Yes/No/Contraindicated
management?
Topics – prognosis,
Yes/No
management, dietary salt
symptoms?
restriction, fluid & alcohol
intake, physical activity
Yes/No/Don’t know
ABC smoking cessation
advice given?
Yes/No/NA
worsening
Yes/No
Patient
monitoring of
weight
discussed?
Yes/No/NA
Comments:
Patient 8 (add initials/NHI):
Information/ advice
Target weight
Action plan for
Suitability for
Recall for annual
provided on heart
range
patient
exercise
influenza &
failure and self-
recorded?
discussed in
programme
pneumococcal
event of
assessed?
vaccinations in PMS
Yes/No
Yes/No/Contraindicated
management?
Topics – prognosis,
Yes/No
management, dietary salt
symptoms?
restriction, fluid & alcohol
intake, physical activity
Yes/No/Don’t know
ABC smoking cessation
advice given?
Yes/No/NA
worsening
Yes/No
Patient
monitoring of
weight
discussed?
Yes/No/NA
Comments:
8
Patient 9 (add initials/NHI):
Information/ advice
Target weight
Action plan for
Suitability for
Recall for annual
provided on heart
range
patient
exercise
influenza &
failure and self-
recorded?
discussed in
programme
pneumococcal
event of
assessed?
vaccinations in PMS
Yes/No
Yes/No/Contraindicated
management?
Topics – prognosis,
Yes/No
management, dietary salt
symptoms?
restriction, fluid & alcohol
intake, physical activity
Yes/No/Don’t know
ABC smoking cessation
advice given?
Yes/No/NA
worsening
Yes/No
Patient
monitoring of
weight
discussed?
Yes/No/NA
Comments:
Patient 10 (add initials/NHI):
Information/ advice
Target weight
Action plan for
Suitability for
Recall for annual
provided on heart
range
patient
exercise
influenza &
failure and self-
recorded?
discussed in
programme
pneumococcal
event of
assessed?
vaccinations in PMS
Yes/No
Yes/No/Contraindicated
management?
Topics – prognosis,
Yes/No
management, dietary salt
symptoms?
restriction, fluid & alcohol
intake, physical activity
Yes/No/Don’t know
ABC smoking cessation
advice given?
Yes/No/NA
worsening
Yes/No
Patient
monitoring of
weight
discussed?
Yes/No/NA
Comments:
9
Patient 11 (add initials/NHI):
Information/ advice
Target weight
Action plan for
Suitability for
Recall for annual
provided on heart
range
patient
exercise
influenza &
failure and self-
recorded?
discussed in
programme
pneumococcal
event of
assessed?
vaccinations in PMS
Yes/No
Yes/No/Contraindicated
management?
Topics – prognosis,
Yes/No
management, dietary salt
symptoms?
restriction, fluid & alcohol
intake, physical activity
Yes/No/Don’t know
ABC smoking cessation
advice given?
Yes/No/NA
worsening
Yes/No
Patient
monitoring of
weight
discussed?
Yes/No/NA
Comments:
Patient 12 (add initials/NHI):
Information/ advice
Target weight
Action plan for
Suitability for
Recall for annual
provided on heart
range
patient
exercise
influenza &
failure and self-
recorded?
discussed in
programme
pneumococcal
event of
assessed?
vaccinations in PMS
Yes/No
Yes/No/Contraindicated
management?
Topics – prognosis,
Yes/No
management, dietary salt
symptoms?
restriction, fluid & alcohol
intake, physical activity
Yes/No/Don’t know
ABC smoking cessation
advice given?
Yes/No/NA
worsening
Yes/No
Patient
monitoring of
weight
discussed?
Yes/No/NA
Comments:
10
Patient 13 (add initials/NHI):
Information/ advice
Target weight
Action plan for
Suitability for
Recall for annual
provided on heart
range
patient
exercise
influenza &
failure and self-
recorded?
discussed in
programme
pneumococcal
event of
assessed?
vaccinations in PMS
Yes/No
Yes/No/Contraindicated
management?
Topics – prognosis,
Yes/No
management, dietary salt
symptoms?
restriction, fluid & alcohol
intake, physical activity
Yes/No/Don’t know
ABC smoking cessation
advice given?
Yes/No/NA
worsening
Yes/No
Patient
monitoring of
weight
discussed?
Yes/No/NA
Comments:
Patient 14 (add initials/NHI):
Information/ advice
Target weight
Action plan for
Suitability for
Recall for annual
provided on heart
range
patient
exercise
influenza &
failure and self-
recorded?
discussed in
programme
pneumococcal
event of
assessed?
vaccinations in PMS
Yes/No
Yes/No/Contraindicated
management?
Topics – prognosis,
Yes/No
management, dietary salt
symptoms?
restriction, fluid & alcohol
intake, physical activity
Yes/No/Don’t know
ABC smoking cessation
advice given?
Yes/No/NA
worsening
Yes/No
Patient
monitoring of
weight
discussed?
Yes/No/NA
Comments:
11
Patient 15 (add initials/NHI):
Information/ advice
Target weight
Action plan for
Suitability for
Recall for annual
provided on heart
range
patient
exercise
influenza &
failure and self-
recorded?
discussed in
programme
pneumococcal
event of
assessed?
vaccinations in PMS
Yes/No
Yes/No/Contraindicated
management?
Topics – prognosis,
Yes/No
management, dietary salt
symptoms?
restriction, fluid & alcohol
intake, physical activity
Yes/No/Don’t know
ABC smoking cessation
advice given?
Yes/No/NA
worsening
Yes/No
Patient
monitoring of
weight
discussed?
Yes/No/NA
Comments:
Patient 16 (add initials/NHI):
Information/ advice
Target weight
Action plan for
Suitability for
Recall for annual
provided on heart
range
patient
exercise
influenza &
failure and self-
recorded?
discussed in
programme
pneumococcal
event of
assessed?
vaccinations in PMS
Yes/No
Yes/No/Contraindicated
management?
Topics – prognosis,
Yes/No
management, dietary salt
symptoms?
restriction, fluid & alcohol
intake, physical activity
Yes/No/Don’t know
ABC smoking cessation
advice given?
Yes/No/NA
worsening
Yes/No
Patient
monitoring of
weight
discussed?
Yes/No/NA
Comments:
12
Patient 17 (add initials/NHI):
Information/ advice
Target weight
Action plan for
Suitability for
Recall for annual
provided on heart
range
patient
exercise
influenza &
failure and self-
recorded?
discussed in
programme
pneumococcal
event of
assessed?
vaccinations in PMS
Yes/No
Yes/No/Contraindicated
management?
Topics – prognosis,
Yes/No
management, dietary salt
symptoms?
restriction, fluid & alcohol
intake, physical activity
Yes/No/Don’t know
ABC smoking cessation
advice given?
Yes/No/NA
worsening
Yes/No
Patient
monitoring of
weight
discussed?
Yes/No/NA
Comments:
Patient 18 (add initials/NHI):
Information/ advice
Target weight
Action plan for
Suitability for
Recall for annual
provided on heart
range
patient
exercise
influenza &
failure and self-
recorded?
discussed in
programme
pneumococcal
event of
assessed?
vaccinations in PMS
Yes/No
Yes/No/Contraindicated
management?
Topics – prognosis,
Yes/No
management, dietary salt
symptoms?
restriction, fluid & alcohol
intake, physical activity
Yes/No/Don’t know
ABC smoking cessation
advice given?
Yes/No/NA
worsening
Yes/No
Patient
monitoring of
weight
discussed?
Yes/No/NA
Comments:
13
Patient 19 (add initials/NHI):
Information/ advice
Target weight
Action plan for
Suitability for
Recall for annual
provided on heart
range
patient
exercise
influenza &
failure and self-
recorded?
discussed in
programme
pneumococcal
event of
assessed?
vaccinations in PMS
Yes/No
Yes/No/Contraindicated
management?
Topics – prognosis,
Yes/No
management, dietary salt
symptoms?
restriction, fluid & alcohol
intake, physical activity
Yes/No/Don’t know
ABC smoking cessation
advice given?
Yes/No/NA
worsening
Yes/No
Patient
monitoring of
weight
discussed?
Yes/No/NA
Comments:
Patient 20 (add initials/NHI):
Information/ advice
Target weight
Action plan for
Suitability for
Recall for annual
provided on heart
range
patient
exercise
influenza &
failure and self-
recorded?
discussed in
programme
pneumococcal
event of
assessed?
vaccinations in PMS
Yes/No
Yes/No/Contraindicated
management?
Topics – prognosis,
Yes/No
management, dietary salt
symptoms?
restriction, fluid & alcohol
intake, physical activity
Yes/No/Don’t know
ABC smoking cessation
advice given?
Yes/No/NA
worsening
Yes/No
Patient
monitoring of
weight
discussed?
Yes/No/NA
Comments:
14
RNZCGP Summary Sheet
Continuous Quality Improvement (CQI) Activity
Topic:
Heart Failure with Left Ventricular Systolic
Dysfunction: Non-Pharmacological
Management
Doctor's name: ________________________________________________________________
First cycle
Data: Date of data collection:
Check: Describe any areas targeted for improvement as a result of analysing the data collected.
Action: Describe how these improvements will be implemented
Monitor: Describe how well the process is working. When will you undertake a second cycle?
Second cycle
Data: Date of data
collection:
Check: Describe any areas targeted for improvement as a result of analysing the data collected.
Action: Describe how these improvements will be implemented.
Monitor: Describe how well the process is working.
Comments:
16