Community Heart Failure Team

The Heart Failure Specialist nursing team was formed during 2013 and consists of 3 specialist Heart Failure nurses. Referrals are accepted from all health care professions when a patient has a confirmed diagnosis of left ventricular systolic dysfunction via echocardiogram or similar test. The aim of the service is to help stabilise and optimise the patient’s condition and help them develop self management strategies.
For all other types of Heart Failure, i.e. valve disease with preserved Heart Failure, the referral with a plan of action needs to be made via a Cardiologist.

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Referral criteria

The patient must have a confirmed diagnosis of left ventricular systolic dysfunction

Excluded:

Heart Failure where the cause is so far undiagnosed
Heart Failure secondary to valve disease or hereditary condition, unless referred by the consultant cardiologist
Heart Failure secondary to hypertensive disease or isolated right Heart Failure unless referred by the consultant cardiologist
Paediatric patients

Patients with a confirmed diagnosis of left ventricular systolic dysfunction are referred :-

On hospital discharge
From secondary care clinic
From GPs
From other Community healthcare professionals

Health Professional?

Full service description

As a team, the Heart Failure Nurses provide care by:

Managing complex drug regimes and encouraging compliance
Titration of Heart Failure medication in line with NICE Guidelines
Monitoring patient response, bloods and organ function following drug changes
Liaising with acute hospital Heart Failure specialists both nurses & consultants to create a “pull” model for early discharge
Educating patients and carers to know how to recognise & manage exacerbations thereby avoiding unnecessary admission & taking control of their condition
Encouraging lifestyle improvements including, in association with relevant professionals, advice about exercise & diet
Utilising tele-monitoring and monitoring vulnerable patients daily via the remote system
Tailoring care to individual patient needs and provide individualised care plans
Ensuring all Heart Failure patients benefit from flu & pneumococcal immunisation
Delivering improved patient & carer experience at the end of life including where appropriate de-activation of intra-cardiac devices in conjunction with appropriate palliative care teams
Build on and encourage best practice in primary care by providing education to other healthcare professionals and providing advice when sought
Improve the prognosis & quality of life for Heart Failure patients by improving symptoms & slowing their deterioration