The pandemic has been challenging for everyone; no one will come out of this experience unscathed. But people living with long-term conditions such as heart failure, who require regular review and access to health and social care services, have faced incredibly difficult times. Redeployment of staff to front-line care has reduced heart failure services, in some areas to nothing. As a result, many of the patients we care for have had limited or no access to their heart failure teams. This has significantly impacted the timely optimisation of therapies for heart failure, which improve outcomes and keep people out of hospital.
Before the first lockdown in March 2020, hospital admissions for heart failure in the UK had risen by nearly a third over the course of five years, to more than 100,000 per year. This may reflect the growing number of people developing heart failure, as well as missed opportunities to diagnose and treat people before they become unwell and need to be admitted to hospital.
During the pandemic, we have seen a substantial drop in admissions for heart failure. Some people were fearful of attending hospital because of the risks of contracting COVID-19. One study showed that while admissions were lower, community mortality was higher. This raises huge concerns and highlights exactly why heart failure services should be maintained throughout these uncertain times.
At Imperial College Healthcare NHS Trust, we have kept our heart failure services going despite redeployment of key staff. We managed the inevitable risks posed by face-to-face review by moving to virtual reviews and re-locating in-person consultations to sites outside of acute hospitals. Despite this, fear of contracting COVID-19 drove many people to decline appointments and not seek medical help.
The pandemic has driven innovation, as we had to seek solutions to provide rapid support to patients. Initiatives that might have taken years to develop have come to fruition in massively shorter time frames. For example, we undertook an integrated pathway redesign, seeking patient input and pulling together a team spanning hospital and primary care. The team’s overall ambition: to improve the outcomes and experience for heart failure patients by creating long-term, sustainable changes to the care pathway. We also aimed to improve the identification, referral and thus diagnosis of heart failure, so that people could access life-preserving treatments sooner, keeping them out of hospital and living well for longer.
During the pandemic, the trust introduced a remote monitoring platform that allows patients to use Bluetooth blood pressure monitors, heart rate monitors and weighing scales, which upload data to a smartphone app. The app is equipped with educational modules developed by the trust’s heart failure team. It contains patient questionnaires that enable the nurses to review and support the person’s psychological wellbeing and quality of life, and to collect feedback on how safe they feel using the platform. Nurses review and monitor patient data on a daily basis, which means they can detect signs of deterioration early and enable rapid intervention.
Self-monitoring and knowing that the information is being reviewed by a nurse can reassure patients discharged from hospital or those with a recent diagnosis, who can face a great deal of anxiety. Remote monitoring and virtual review allow us to support more patients more often and to optimise therapies rapidly. It also helps us to address the delays resulting from the pandemic and potential risks moving forward, should there be another health crisis. Many people appreciate the ‘safety net’ provided by remote monitoring and the benefit of not having to take time out to attend appointments, which reduces the impact of their condition on themselves and their families.
Heart failure nurses can improve patient outcomes not only by optimising therapies, but also by educating patients in self-care. The self-care and education elements in the remote monitoring platform are key to empowering patients to manage their condition with confidence in the long term. Patients can continue using the monitoring equipment and app even when optimised, stable and discharged from the nursing service, and can self-refer back to the service as needed. All patients have contact details for the nurses and can get in touch with them directly during office hours.
There are still some challenges with remote monitoring; it is not suitable for everyone. While many people can navigate and manage technology, some do not have smartphones, computers or email. The enrolment criteria for remote services have to be robust. Sometimes objective clinical assessment is essential, but even in this situation, remote monitoring can support patients between appointments.
Whether patients have remote monitoring, virtual or telephone reviews, or face-to-face appointments, what remains key is the integration and partnership between the patient and their primary and secondary care teams. The role of the heart failure nurse is pivotal.
We know that there are around one million people living with heart failure in the UK and this number is expected to grow. The direct and indirect effects of the COVID-19 pandemic will, inevitably, increase the number of people with heart failure who require review more than previously anticipated. We also know that, as a workforce, nurses are seriously under-resourced. Despite clear evidence of the benefit of heart failure nurses for patient outcomes and healthcare costs, we do not have enough nurses to manage the existing number of patients.
We will need to rely on emerging innovations and collaborative care to be able to manage the growing burden of heart failure. We also need to grow the competence of other nurses and allied health professionals to share the load. Towards this goal, the British Society for Heart Failure Nurse Forum has published the first national heart failure nurse competency framework. We hope the framework will help to upskill heart failure nurses from novice to expert and, arguably, bring nursing staff with an interest in heart failure to novice level.
The pandemic has precipitated a rapid response to meet the needs of our patients. Innovative working, increased collaboration across care settings and the creation of different services have been vital in ensuring we continue to support our patients in the manner they deserve and should expect.