The looming presence of COVID-19 threatened specialist nursing services across the UK, with many heart failure nurse specialist (HFNS) teams downsized or even mothballed as members were redeployed to help with increased pressures elsewhere (McDonald, 2021). This was concerning as data from Italy and New York suggested that COVID-19 and heart failure could lead to an adverse prognosis (Bader et al, 2021). This left patients and their families with an immediate withdrawal of their support networks, accompanied by decreased access to primary care at the worst possible time. Fortunately, despite growing staffing pressures within the hospital, the cardiology consultant and operational management teams protected our HFNS service from such reductions. Although COVID-19 threatened many other services, at Portsmouth Hospitals University NHS Trust (PHU) it was a catalyst for change and, with strong support from the heart failure consultant team, COVID-19 inspired the recalibration of our service to better meet patients' needs.
Historically, our HFNS outpatient service was face-to-face, seeing 7–8 patients a day, 5 days a week. To provide a similar level of support and protection, it was necessary to deconstruct the existing components of the ‘in-person’ clinic and explore novel methods of care delivery. Critically, the proposed service had to both maintain accessibility, as some patients were shielding or afraid to visit the hospital, and provide a safe environment for those requiring assessment or treatment to prevent decompensation. Consequently, a novel heart failure clinic was developed incorporating remote telephone monitoring and an ambulatory care unit.
My concern from the outset was one of patients ‘bunkering down’ at home, afraid to be admitted and living with worsening symptoms. Another motivator for change was to prevent patients from feeling cast adrift or abandoned by the health service; not knowing who they should approach if symptoms deteriorated. Telephone contacts were considered ideal, as they encouraged and maintained dialogue between all parties. Furthermore, effective histories would pick up on cues suggestive of decompensation, promoting timely interventions to prevent further deterioration in symptoms and avoiding hospital admissions. Consequently, our HFNS team adopted such a service for its clinical caseload and, although ‘current’ patients were prioritised, I also made every effort to go back through records to identify former patients and re-establish contact. These calls would enquire about symptoms first, sometimes straying onto other topics, but all ended with a reminder that the PHU HFNS service was running and available to them if needed. Perceptions are important and I was conscious that although they were often only quick conversations, they would be valued by those being checked on. Unbeknown to me, this view was validated in the supporting evidence for my nomination, as a 72-year-old female patient commented that I was the only health professional to check up on her, while a 91-year-old female expressed gratitude that I had taken the time to make sure she was OK.
I found the telephone clinic, either for remote monitoring, medication up-titration, or for touching base with patients, to be an effective and efficient method of running the HFNS service. For some it was ideal, but it left the challenge of what to do with patients whose symptoms suggested decompensation. A safe area was needed to undertake physical assessments and investigations, as well as provide treatments such as intravenous diuretics to prevent inpatient admissions. My solution, with the backing of the heart failure consultants, was to develop an ambulatory service to run alongside the telephone one.
Although ambulatory clinics are not a new concept and have been successfully run for numbers of years elsewhere, PHU, and the Wessex area, did not have one before the pandemic. COVID-19 created the perfect opportunity to explore the establishment of one as it brought about the suspension of all elective cardiac procedures. Suddenly, the cardiac day unit (CDU) was available—14 beds and a team of nurses. After presenting my plan to the medicine leadership team (MLT) formal authorisation was granted to make use of the available resources—I have to stress that without the commitment of the MLT and CDU teams, the ambulatory service would not have gone ahead. Furthermore, when reflecting on the successes of the clinic, the unwavering support of the cardiac physiologists must also be highlighted. It was a truly multidisciplinary service.
Thanks to the enthusiasm of the CDU staff, I could run both the ambulatory and outpatient telephone clinics, as they oversaw patient care throughout the appointment. This allowed me to focus on reviewing patients, establishing treatment plans or prescribing necessary medications, and provided the freedom to leave CDU to continue scheduled telephone clinics. Although it was my name on the nomination, I can recall many episodes of the CDU staff going beyond their remit, helping patients with grocery shopping due to shielding or visiting them on a ward for non-cardiac admissions.
The frequency of visits to the ambulatory clinic would depend on the individual's clinical requirements. For some the schedule of visits was intensive, avoiding a hospital admission. Others would attend periodically over the year to improve their symptom burden and quality of life. I still have patients who used the service asking about the CDU staff during routine telephone follow-up calls.
Heart failure has been a longstanding challenge to the health service (Conrad et al, 2018) and continued to be so during the COVID-19 pandemic with patients still requiring HFNS reviews in the hospital. Although our aim was to prevent the admission of existing patients and keep them away from the emergency department, new diagnoses continued and the HFNS team actively targeted inpatients with the intention of facilitating early discharges. As the medical assessment unit (MAU) and short stay ward were considered areas where the probability of a COVID-19 contact was high, other HFNS team members proactively searched the hospital's electronic patient record system for patients on those wards whose symptoms were suggestive of heart failure. This sped up specialist reviews, investigations and interventions. Where appropriate we would arrange urgent follow up by community HFNS colleagues to expedite discharge or, if not, invite patients to the new clinic as a bridging service until they could take over. The first patient identified for the ambulatory service was found this way, having been diagnosed with both severe heart failure and advanced cancer. By organising an early discharge and urgent ambulatory treatment the patient got to spend more time with his wife than he would have been able to. Before his discharge from the ambulatory clinic, both patient and wife expressed their thanks for the continued support as it had stabilised his symptoms until community services could intervene.
While targeted searches were carried out for inpatients with all forms of heart failure, locally the community HFNS are not currently commissioned to review patients with heart failure with preserved ejection fraction (HFpEF). As this population are as likely to develop debilitating symptoms or be admitted to hospital, we ensured that those ineligible for normal follow up, for whatever reason, received a phone call to check on their symptoms once discharged from the hospital—providing another layer of safety unique to this clinic. Although including this patient group generated more calls from concerned patients about developing symptoms, for the most part they were managed by telephone consultations. Occasionally some described worrying symptoms and were invited to the ambulatory clinic for assessment regardless of disease pathology.
It is important to stress that the new ambulatory clinic was more than a ‘diuretic lounge’. In its first 6 months of operation, 66 patients were reviewed across 136 appointments, with 44 having their medications optimised (Green et al, 2020). Where appropriate, this included early transition to a sacubitril/valsartan combination and from February 2021, the addition of dapagliflozin. While 49% of the reviewed patients received intravenous diuretics, on occasions intravenous iron and blood transfusions were organised to improve symptoms and prevent admission. In that initial 6 months only 6 patients were directly admitted as cardiology inpatients. Following the end of the first wave, elective cardiac procedures resumed, and CDU was designated a ‘COVID-free zone’ requiring patients to have negative COVID-19 swabs 72 hours prior to visiting. Despite the logistical complication and reduced bed availability due to elective procedures, working with ward and service managers, I secured 18 patient appointments a week, plus two echocardiography scans a day. This permitted the service to continue during the second wave.
It was an honour to be nominated for this award by Mrs Rosalynn Austin, the Principle Clinical Academic Nurse Researcher, and the heart failure consultants. I think it is important to acknowledge the support of many others in getting these services off the ground: the medical leadership team: Senior Lead Nurse, Mrs Nichola Martin; General Manager for Medicine, Mr Martin Fuller; Cardiology Matron, Mrs Krissie Arnott; the heart failure consultant team: Professor Paul Kalra; Dr Geraint Morton; Dr Kaushik Guha; the heart failure nurse specialist team led by Mrs Dawn Lambert; and the cardiac day unit team led by Mr Martin Drew.
By sharing my experiences of creating, co-ordinating and adapting this novel telephone and ambulatory heart failure service, I hope that others will be similarly inspired to develop their clinics if they identify better ways to support patients. Furthermore, I believe it shows that, in times of unexpected challenges, as with COVID-19, dedicated specialist teams should not be withdrawn from their patients but be encouraged to innovate and redesign service provision, to ensure patients continue to receive support when they need it most.