Heart failure: take heart

Robert Millett meets a physiotherapist who is helping patients at a pioneering heart failure unit.

Research suggests that people with heart failure are more likely to survive if they receive treatment in a cardiology ward, rather than in a general hospital setting. The latest National Heart Failure Audit shows that cardiology-based care is associated with a 40 per cent reduction in mortality, and in 2014 the National Institute for Health and Care Excellence (NICE) recommended that all hospitals should have specialist, cardiology-based teams.
In line with this advice a pioneering unit opened this year at St George’s Hospital in south London, part of St George’s University Hospitals NHS Trust. The trust believes the specialist centre is the first of its kind in both the UK and mainland Europe. It was set-up with funding of £1.42 million from the trust’s clinical commissioning group and NHS England’s commissioning for quality and innovation initiative.
Susan Eriksen, a highly specialist physiotherapist, is part of the unit’s multidisciplinary team. She says that the 11-bed centre provides a consultant-led, patient-centred service that aims to improve the care of people with acute and chronic heart failure. ‘Audits show that if a patient is in a cardiology ward then that alone increases their outcomes,’ she says. ‘So what we are doing is improving that further by treating them on a specialist unit with specialist staff.’
Ms Eriksen explains that heart failure occurs when the heart is unable to efficiently pump blood around the body. It affects around 900,000 people in the UK at any time and the most common causes are heart attacks, high blood pressure and cardiomyopathy (diseases of the heart muscle). ‘The average age of inpatients on the unit is around 75,’ says Ms Eriksen. ‘But we have had people as young as 40 and as old as 98.’
In the past heart failure had a poor prognosis, says Ms Eriksen, but mortality rates have fallen due to medical advances. These include the use of medications such as beta blockers and angiotensin-converting enzyme inhibitors [which reduce high blood pressure] and treatments such as cardiac resynchronisation therapy, in which an implanted device is used to resynchronise the contractions of the heart’s ventricles.
But Ms Eriksen says corresponding improvements have not been made to identify ‘how best to treat patients in an acute hospital situation’ to maximise their wellbeing.‘People are living longer, but aren’t necessarily living better – so what we are trying to do is improve their quality of life.’

The benefits of exercise

The team includes four consultants, two clinical fellows, specialist heart failure nurses, a highly specialised occupational therapist, a dietician and a cardiothoracic pharmacist. Ms Eriksen provides ward-based physiotherapy – focusing on mobility, respiratory and discharge planning – along with specialist exercise prescription, goal setting and onward referrals to cardiac rehab. She also gives patients exercise education, such as using heart rates to identify an ‘optimal training range’ that will maximise the benefits of any exercise. 
‘A lot of people with a heart problem shy away from exercise, but the research out there shows that it’s really important and beneficial for them to be active,’ she explains. ‘So it’s about making them aware that they should be active every day, explaining what sort of things constitute activity, how to progress in a sensible, controlled manner and how to know if they are working too hard or not hard enough.’ With this information discharged patients are able to continue to exercise and improve, she adds.
Referrals can come from any area of the hospital or the community. The service commonly treats people with acutely decompensated heart failure. This is when a person with chronic heart failure has worsening symptoms, such as swelling of the feet and legs, breathing difficulties and fatigue. 
‘When that happens they have a build-up of fluid around the lungs and the body, so they put on quite a lot of weight and can get tired and short of breath,’ says Ms Eriksen. These patients often find normal levels of activity hard to maintain and can even find walking difficult, due to the accumulation of fluid in their legs. 
‘We have people at varying levels of function and some younger people, who are overloaded with fluid, can still walk reasonably well,’ she says. ‘But when older, less mobile patients are affected by extra fluid then just getting out of bed can be quite a feat for them.’ 

Patient education is key

Decompensated patients receive an intravenous diuretic [medication that increases the production of urine]. This helps the body to ‘offload’ accumulated fluid and allows the heart to work more functionally. But patients must be connected to an IV pump, which can severely restrict activity, says Ms Eriksen. ‘On a general medical ward they might just go from bed to chair for days on end without mobilising, because they are offloading and haven’t been seen by a physiotherapist yet – and that means that they are actively getting weaker,’ In contrast, all decompensated patients in the unit receive early physiotherapy, which helps to prevent hospital-related deterioration. This often includes range of motion exercises and lower and upper limb strengthening, which can be performed bedside or in the unit. 
‘The outcomes so far have shown that as well as preventing deterioration in “higher level” patients, the “lower level” ones are being made stronger before they leave hospital - which doesn’t usually happen - as normally they’d leave much weaker.’ 
Six months after opening in January, inpatient mortality rates on the unit were 4.5 per cent, in comparison to figures from the National Heart Failure Audit, which reveal a national average of 9.4 per cent. In addition, 30 days after leaving the centre there were no deaths among discharged patients, which, Mrs Erikson says, is a significant improvement on the national average of 5.4 per cent for patients treated in cardiology settings. The unit has also cut the number of patients readmitted with decompensated heart failure within 28 days, and reduced all cause readmission rates.
Physiotherapy-specific data has also been collected by Ms Eriksen to analyse the effectiveness of her input. This shows that, out of 40 patients and six months after opening, 85 per cent felt physiotherapy had helped them during their stay. And all patients reported that Ms Eriksen’s input had provided a good understanding of how exercise could help their condition.
‘I had one patient who become very emotional after I took him on the stairs and provided exercise education and advice,’ she says. ‘He was blown away with the change in his exercise tolerance from admission to discharge. But on a normal cardiology ward he wouldn’t have been seen by a physio as he was mobile and independent.’
Data collected from 45 patients also indicated that physiotherapy prevented deterioration while on the ward and improved functional outcomes. And almost half (46 per cent) of all suitable patients were referred on to cardiac rehabilitation in the community, which is much higher than the national average of less than 10 per cent.
Ms Eriksen intends to continue to focus on early intervention, preventing deterioration and providing education that will help patients after discharge and improve their long-term quality of life. ‘The majority of patients are open to it,’ she says. ‘And the better educated a person is around their condition the less likely they are to come back into hospital and the more likely they are to enjoy their life.’ fl 

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Robert Millett

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