Personalised Cardiac Rehabilitation Outreach Service Reduces Mortality and Hospitalisations in Heart Failure with Reduced Ejection Fraction

BackgroundHeart failure (HF) has become a major cause of morbidity and mortality worldwide. Despite significant improvements in the management of HF, the overall outcomes remain poor. In addition to pharmacotherapy and device therapy, non-pharmacological interventions are needed to mitigate the effects of this illness. The aim of this study was to evaluate the impact of the heart failure outreach program on the rate of mortality, HF hospitalisations and guideline directed medical therapy (GDMT) for HF in South Western Sydney Local Health District (SWSLHD).MethodsIn this observational, registry based study, adult patients diagnosed with Heart failure with reduced ejection fraction (HFrEF) within the South Western Sydney Local Health District (SWSLHD) and invited to participate in the heart failure outreach service between March 2011 and January 2016 were included in the study. The primary outcome was all-cause mortality. In addition, we examined the rate of optimal medical therapy, HF hospitalisations and the total lengths of stay.ResultsA total of 818 patients were included in the study; 470 (57.5%) patients were enrolled and 348 (42.5 %) not enrolled into the program. At the end of the follow up period (median 978 days, interquartile range (IQR) 720-1237), the primary outcome of mortality was observed significantly less in the enrolled group (122 (26%) vs. 133 (38.2%), p<0.001) independently of other variables. In addition, significantly fewer enrolled patients had >3 hospital admissions for HF (16.2% vs. 35.6%, p<0.001) and reduced median admission days (14.5 days [IQR 8-25] vs 22 [IQR 12-37], p <0.001). Patients enrolled into the program were much more likely to be on GDMT (76.6% vs 56.6%, p<0.001).ConclusionsEnrolment in the heart failure outreach program was associated with a significant reduction in mortality as well as a reduction in the frequency and length of hospital admissions. In addition, the rate of GDMT was significantly higher in the enrolled group. With the high prevalence of heart failure, these programs should be considered in the routine management of patients with HFrEF.

Treating COVID-19 in the nursing home setting: an integrated approach for a complex and susceptible cohort

ABSTRACT Our patient, a nursing home resident, was reviewed by our frailty outreach service in November 2020. She initially was diagnosed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in September 2020 during an outbreak in her nursing home. On this occasion, she again tested positive for SARS-CoV-2. Our case report describes the resident’s poor immune response indicated by a low IgG level after her initial COVID infection as well as reinfection with a ‘non-variant’ SARS-CoV-2 lineage (B.1.177). The case describes the importance of integration of community and secondary care. The nursing home received close monitoring and nurse supervision for the detection of potential deterioration of the patient. Exit-seeking behaviour by nursing home residents was limited effectively. The issues of low immune response to COVID-19 in older people and the emergence of variants of concern will continue to pose a threat to this susceptible group.

Home Before Hospital: A Whole of System Re-Design Project to Improve Rates of Home–Based Dialysis Therapy: Experience and Outcomes Over 8 Years

Background Despite evidence that clinical outcomes for patients treated with peritoneal dialysis or home haemodialysis are better than for patients treated with conventional satellite or hospital-based haemodialysis, rates of home-based dialysis therapies world-wide remain low. Home-based dialysis care is also cost effective and indeed the favoured dialysis option for many patients. Methods Using a lean-thinking framework and established change management methodology, a project embracing a system-wide approach at making a change where a Home before Hospital philosophy underpinned all approaches to dialysis care was undertaken. Three multidisciplinary working groups (Pathway, Outreach and Hybrid) were established for re-design and implementation. The primary aim was to improve home-based dialysis therapy prevalence rates from a baseline of 14.8% % by ≥2.5 %/year to meet a target of 35%, whilst not only maintaining but improving the quality of care provided to patients requiring maintenance dialysis. A future state pathway was developed after review of the current state (Pathway Working Group) and formed the basis on which a nurse-led Outreach service (Outreach Working Group) was established. With the support of the multidisciplinary team, the Outreach Service model focussed on early, consistent, and frequent education, patient support in decision making, and clinician engagement. Results A target prevalence of &gt;30 % for home-based therapies (mainly achieved with peritoneal dialysis) was achieved within 2 years. This prevalence rate reached 35% within 3 years and was maintained at 8 years. In addition, selected patients already on maintenance satellite-based haemodialysis (Hybrid Working Group) were educated to achieve high levels of proficiencies in self-care. Conclusion Having the system-wide approach to a Quality Improvement Process and using established principles and change management processes, the successful implementation of a new sustainable model of care focused on home-based dialysis therapy was achieved. A key feature of the model (through Outreach) was early nurse-led education and support of patients in decision making and ongoing support through multidisciplinary care.