HomeMedicine By SpecialtyCardiologyMulti-specialty team reduces admissions, wait times for heart failure patients

Multi-specialty team reduces admissions, wait times for heart failure patients

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When patient David Northey runs into difficulty managing his heart failure, he knows he can call the Heart Function Clinic at St. Mary’s General Hospital in Kitchener and often be seen the same day.

This quick access to a highly-skilled, multidisciplinary team at the hospital’s regional cardiac care centre improves quality of life for vulnerable patients like David, and reduces admissions and emergency department (ED) visits.

The Heart Function Clinic at St. Mary’s operates on a model that gives nurses a high level of autonomy, which sets the clinic apart. Patients belong to the clinic, not a specific physician. In a physician-focused model, patients must wait to be seen until their physician is available, which lengthens wait times. At St. Mary’s, cardiologists rotate through the clinic and registered nurses and nurse practitioners provide the bulk of the care.

“Many heart function clinics are physician driven where ours is nursing driven,” says Jeannine Costigan, a nurse practitioner with the clinic. “Nurses are able to play a leadership role, which delivers continuity for patients by allowing them to always see the same nurses. If you’re held to a physician’s schedule, you can’t follow patients as well or see as many.”

Dr. Stuart Smith, Chief of Cardiovascular Services at St. Mary’s, says the clinic’s patients don’t need to see a cardiologist at every visit.  “These nurses are very skilled and the protocols are very straightforward. The physicians handle more of the diagnostic dilemmas,” he says.

This efficient use of resources allows for more patients to be seen, often in the same day if they develop urgent issues. If they are feeling unwell and they have a device such as a pacemaker or implantable cardioverter defibrillator, they can have their device checked during their appointment.

“Everybody here is fantastic,” says patient David Northey. “They are very professional and go the extra little bit to make sure you are well taken care of. If you are having trouble, you call and they get you right in.”

Nurses can administer intravenous Lasix to patients who develop fluid retention, which helps prevent unneccesary emergency department (ED) visits. They also provide detailed instructions prior to weekends when the heart function clinic is closed. Five to nine ED visits are avoided every month as a result of these measures.

From April 1, 2011, to March 31, 2012, the clinic had 1,425 visits. As a result of clinic interventions, 169 admissions or ED visits may have been prevented in that period.

Patients enjoy the one-stop shopping approach. On the same visit, they are often seen by multiple professionals for assessments, diagnostic and device testing, symptom management advice and medication adjustments. With the help of other disciplines as required, the clinic offers medical evaluation, exercise instruction, risk factor modification, education, counselling, behavioural interventions and advice on healthy heart living.

The Heart Function Clinic has expertise in heart failure and transplantation, and is integrated with the Pacemaker and Device Clinic, which has expertise in ICDs, biventricular pacing and electrophysiology. Their close proximity allows cross-communication between the experts in these areas, so the health-care team has all relevent information to provide the best quality holistic care. Cardiodiagnostic services are located adjacent to the clinics to offer quick access when needed.

Even when heart failure patients are discharged from hospital, the Heart Function Clinic nurses remain involved. “We provide rapid follow-up with a phone call to make sure they understand discharge and medication instructions,” Maureen Leyser, a nurse practitioner with the clinic says. The team also works with the Community Care Access Centre, offering advice for home care.

“The level of teamwork and integration in the Heart Function Clinic, and the fact that it is hospital-funded, is somewhat unique,” says Dr. Smith. So too is the involvement of dietitians, a geriatrician and a palliative care specialist. The clinic also consults with nephrologists, endocrinologists and respirolgists because cardiac patients often have diabetes, kidney disease and chronic obstructive pulmonary disease.

The clinic also co-shares patients with the transplant team at Toronto General Hospital, monitoring local patients before transplant, including those with left ventricular assist devices. St. Mary’s also monitors patients after transplant and performs regular biopsies.

St. Mary’s hopes to soon have approval from the Ministry of Health and Long-term Care for a full arrhythmia program, which would add ICD implantation and ablation to its services.”We can address all aspects of the care from new diagnosis to palliative care,” Dr. Smith says.

Improvements in treatment and disease management are lengthening life expectancies for heart failure patients, he adds. ”Previously there was a 50 per cent mortality rate for heart failure patients within five years,” says Dr. Smith. “Now it is closer to 10 years.”


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