East Berkshire Clinical Commissioning Group (CCG)

Changing the Diuretic IV pathway 2016 – 2018

RightCare works with local health systems to identify innovative practice and share learning. Information briefs are a way of communicating early views of emerging practice. They are designed to raise interest and demonstrate good practice in the development of transformative change across the country.

Summary

Changing the pathway for Diuretic Intravenous (IV) patients from an acute admission to a dedicated supported treatment outpatient facility has reduced spending and improved quality of treatment for patients.

Diagnose – what’s the problem?

In most parts of the UK, intravenous (IV) diuretic therapy for heart failure patients currently requires an inpatient stay and

many patients have repeated and prolonged admissions for recurrent episodes.

RightCare data packs highlighted that East Berkshire CCGs had high numbers of people with heart failure (HF) presenting non-electively.

Review of the heart failure pathway identified that many admissions, some with long lengths of stay, could be prevented or shortened by IV diuretics – medicines that help the body offload excess fluid, given on a day case basis.

“With admissions lasting on average 10 days, being permitted to return home after treatment each day not only improves quality of life for our patients but also reduces the risk of complications associated with lack of mobility and sleep deprivation, which are often linked with long hospital stays.” Clinical Nurse Specialist

Develop – what they changed

The health system’s Cardiology Steering Group, with patient representation, took the evidence and developed a new model of care.

The chosen approach was an acute-based diuretic IV lounge to improve patient experience and avoid admissions. This approach was favoured by clinicians compared to a community-based model.

The diuretic lounge is located within dedicated clinic space on the cardiology ward at Wexham Park Hospital and comprises six reclining infusion chairs; cardiac monitoring with access to a cardiac nurse; local medication storage; and infusion equipment.

The lounge opens from 8.00am to 4.00pm seven days a week and is staffed by cardiology ward nurses. Clinical supervision is provided by heart failure (HF) clinical nurse specialists and consultant cardiologists.

HF specialist nurses and clinical nurse specialists assess patients, decide on IV doses of furosemide and optimise HF therapies. Support for healthcare professionals includes clinical pharmacists who perform detailed medication reconciliation and specialty consultation with nutrition, diabetes and palliative care specialists; these are arranged as needed.

On consecutive visits to the lounge, patients are assessed and treated with intravenous diuretics. They are monitored for a maximum of two hours following their daily dose, before going home.

At the end of the course of treatment, patients are discharged with medication and a discharge letter is sent to the patient’s GP.

The pathway is aligned to the RightCare CVD prevention pathway.

A local tariff for the service was agreed with the acute provider.

Deliver – What does the local health system say changed

The local health system says that the change supports self-care, shared decision making and enables direct signposting to lifestyle and wellbeing services.

For this patient group there was a 61% reduction in non-elective inpatient admissions in 2017/18 compared with the previous financial year.

By changing the treatment setting, the intervention is thought to have contributed to increased capacity on the inpatient cardiology ward at Wrexham Park hospital through reduced lengths of stay for this treatment cohort.

What next? – learning points from the local system

A strong patient voice linked to national heart groups and the British Heart Foundation helped to stimulate and maintain the pressure for changes to the pathway. Support from the Thames Valley Cardiology Network was also influential.

Locating the service within the cardiology ward is a key success factor due to clinical links with the cardiologists and specialist nursing team.

Identifying the physical space on the cardiology ward and agreeing the change in use of the cardiology inpatient beds was progressed with support from system leaders who unlocked the bed utilisation issues.

With thanks to:

  • Sangeeta Saran, Associate Director Planned Care, East Berkshire CCG
  • Dr Nithya Nanda, CVD GP Lead, East Berkshire CCG
  • Dr Peter Clarkson, Consultant Cardiologist, Frimley Health Foundation Trust,
  • Dr Bruce Pollington, Delivery Partner, RightCare

For more information please contact rightcare@nhs.net