Northumbria Healthcare NHS Foundation Trust, Unit 7/8, Silver Fox Way, Cobalt Business Park, Newcastle Upon Tyne, Tyne and Wear, NE27 0QJ (“Trust”)

Project Name: Service improvement for the detection and treatment of Heart Failure (“HF”) in secondary care

Project Summary:

The aim of the proposed JWP is to improve identification, monitoring, management and treatment of HF patients in secondary care via:

• the extension of the current hospital based specialist HF service through the deployment of an “in-reach” nurse with the purpose of identifying and triaging HF patients (both at acute medical receiving units and non Cardiology departments) so they can be appropriately referred and receive specialist HF input;
• the utilisation of a bespoke HF patient database (the “Database”):the Database will facilitate the identification of new HF patients and the management of existing HF patients in secondary care;
• the implementation of a Multi-Disciplinary Team (“MDT”); and the increase of capacity of the current out-patient HF Specialist Clinic.

The activity of the ‘in-reach’ nurse, the proactive review of the Database by HF specialist nurses (the “HFSN”) and scrutiny by the MDT of the most complex cases will promote timely and appropriate follow-up care, which may include attendance at additional outpatient HF Specialist Clinic, based in secondary care.

Planned Milestones:

Expected Benefits:

Patients:

• improved access to optimal diagnosis and treatment;
• more equitable and consistent care and access to care;
• enhanced experience for patients who live with HF and their carers.

Trust:

• increase the overall quality of care and improve equity of access to specialist care for patients with HF;
• improve patient flow and reduce total number of unplanned admissions due to HF;
• increase proportion of patients with HF being managed in accordance with NICE guideline standards;
• insight into benefits of an enhanced HF service which may inform ongoing redesign and workforce planning.

Novartis:

• further opportunities for the appropriate use of cardiology licensed medicines in line with NICE guidelines, including Novartis’ medicine;
• improved professional and transparent relationship and trust between Novartis and the NHS.

Start Date & Duration: October 2019, 47 months

UK2306123691
UK | July 2023 | 655325

Project Name: Service Improvement for the detection and treatment of Heart Failure ("HF") in Secondary Care.

Partner Organisation(s): Wansbeck General Hospital (Northumbria Healthcare NHS Foundation Trust) 

Completion Date: October 2023

Outcome Summary:

This project has allowed us to establish an in-reach nurse service with benefits to the quality of acute heart failure care. The comprehensive HF database has supported the delivery of state-of-the-art HF care across our patient cohort.

Key Project Outcomes Data:

• The In-reach nurse service has logged 122 acute encounters, of which 56% were for severe LVSD with approx. half on non-cardiology wards. 40% of these encounters resulted in a change of therapy.
• The database has allowed us to capture 7,961 outpatient encounters with the heart failure nursing team.
• Our data suggests a median of 3 patient visits was required to optimise adherence to the HF guidelines we used. 
• 6 months after their first visit for severe LVSD, between 63.7%-77.4 % of patients were optimised on NICE recommended HF medicines

Outcomes:

The project has improved the identification, monitoring and management of HF patients in the Northumbria Trust.

• The in-reach nurse service has provided an extension of the current hospital-based specialist HF service. They have identified and triaged HF patients at acute medical receiving units and non-Cardiology departments, so patients can be referred and receive specialist HF input. There have been 122 additional acute patient encounters, 40% have resulted in a change in therapy. The in-reach nurse service delivery has provided a legacy of ongoing heart failure input into the acute medical service.
• A bespoke HF patient database was created to record clinical details/parameters/treatments for all HF patients who have contact with the HF service at Northumbria Healthcare. In addition, it offered reminders and prompts if appropriate therapy was not listed. The database has driven high rates of guideline directed medical care and allowed us to demonstrate this for the first time. By project conclusion 7,961 outpatient encounters have been logged by the nursing team into the database. The data collected enabled full service evaluation for the first time, identify variations in practice and move towards streamlined titration of heart failure treatments. This has had clinical and health benefits, it has also enabled the partner organisation to easily identify specific clinical cohorts and therefore has supported the application of patient initiated up programs for these groups in line with current NHS priorities.

Quote from Partner:

"Our joint working collaboration with Novartis has allowed us to develop our heart failure service at Northumbria Healthcare NHS foundation trust. The Novartis team have supported us with this project throughout our long journey working together; helping us navigate the process. Novartis funding has allowed us to introduce a heart failure nurse "in reach" service and to expand our heart failure nursing clinic and MDT provision. We have also been able to design and implement a database for our heart failure patients. This has delivered improvements in the quality of heart failure care for our patients and allowed us to change the way we deliver our services . This Partnership project has allowed us to innovate and develop our models of care." Dr Honey Thomas, Cardiologist.

Conclusion:

The project has allowed a higher identification of HF patients improving patient care and an improved HF service which promotes high quality evidence-based care for heart failure patients. The Database has provided the foundations for a locally bespoke minimum data set database which can meet the needs of the clinical service.

FA-11348109 | February 2025