Abstract
Introduction:
Acute heart failure (HF) is the leading cause of hospital admission in people aged 65 years or older in the UK. Hospital at Home (HAH) is an admission avoidance service for frail older patients with the capabilities of administering intravenous diuretics and carrying out blood test including NT-proBNP. We aimed to audit the diagnosis and management of patients presenting with acute HF to Frimley Health’s HAH services against NICE guidelines (CG187).
Methods:
A retrospective analysis was carried out for all patients referred to HAH with decompensated HF between January and December 2024. Patients referred to HAH from hospital for continuing intravenous treatment were excluded. Patients sent back to hospital after being treated by HAH were also excluded.
Results:
36 patients were treated for acute HF by HAH. 83% patients had a transthoracic echocardiogram (TTE) carried out in the past however only 50% patients had a TTE within the last 24 months. No patients had a TTE whilst under HAH. Type of HF (HFrEF, HFmEF, HFpEF) was documented in 26% of patient notes.
8% of patients had an electrocardiogram (ECG) on admission. 64% patients had NT-pro BNP levels measured. 80% of patients received intravenous loop diuretic treatment. Daily weights were recorded for 75% of patients. Renal function was measured closely with daily urea and electrolytes blood tests for 25% of patients and alternate day monitoring for 70% of patients.
30% of patients were referred to specialist HF services on discharge however only one patient received joint care from HF services whilst under HAH.
Conclusions:
Insights from this audit have helped highlight improvements in practice needed to better align with HF service expectations. A HF template has been created. A reaudit will be carried out after use of template and more collaborative working between HF services and HAH.
Comments
HAH Service Enquiry
Are there Senior Doctors involved in HAH Home Daily Visits? I am just wondering who assess Fluid Balance, review renal functions and adjust IV Diuretics dose? Patients with other co-existing infections such as Cellulitis and community acquired pneumonias be also given antibiotics together with IV Diuretics at home? I just want to know Inclusion and Exclusion Criteria for HAH Services. Thank you.
Criteria for HAH services
Many thanks for your question!
1. Senior Doctors in HAH Home Daily Visits: Yes, we have consultants involved who review new patients or any concerning cases. They typically dictate management plans through a multidisciplinary team (MDT) process. Consultants are available from 8:30 AM to 5 PM, Monday to Friday, with virtual on-call consultations outside these hours available for advice but also for video consultations for any new patients.
2. Fluid Balance and Renal Function Assessment: Both consultants and advanced nurse practitioners assess fluid balance, renal function, and symptoms daily to inform suitable diuretic dosing. We've also piloted the use of portable ultrasounds for better diagnosis, including bedside echocardiograms and evaluating IVC during fluid assessments.
3. Dual Treatment for Infections: Yes, we can administer IV diuretics and antibiotics together for patients needing dual treatment during their once-daily home visits.
Thank you for sharing this…
Thank you for sharing this interesting audit. I noticed that only a small proportion of patients had an ECG on admission in your baseline data. Where do you think the main reasons for this lay? It’s great to see ECGs now incorporated into your new HF template, and I willl be interested to see how this impacts your reaudit.
Services
We have comunity Hert failure nurses in community who do the similar job
Community HF nurses
Amazing! We hope to work with the community heart failure nurses more closely and deliver treatments at home, such as IV diuretics, which may not be available under their service.
Community Health Failure Nurse
We work closely with community heart failure nurses who refer patients to us for IV diuretics, as this is outside their scope of practice. Our hospital-at-home program provides ongoing monitoring and care, facilitating patient transitions back to oral medications when appropriate and referring back to community HF teams for onward management and monitoring.
Thank you for sharing your…
Thank you for sharing your work! I am wondering if there is any certain limit on frequency of IV diuretics on HAH (e.g. is it only once daily or can it be twice daily) for logistic/practical reason? Thank you.
Frequency of IV Diuretics
Thank you for your question! While our standard is once daily, we occasionally accommodate twice-daily visits. We also optimise oral diuretics in the mornings and supplement with IVs for afternoon visits, which tends to work effectively for many patients. We also take urinary sodium levels to identify those patients who may be diuretic naive.
Interesting audit; showing…
Interesting audit; showing significant gaps between national guidelines and local performance. Do you think a template will be enough to address the problem?
Gaps Between Guidelines and Local Performance
Thank your feedback and thank you for your question! While a template may not solve everything, it’s a constructive first step toward aligning our practice with local and national guidelines for heart failure management. We aim to strengthen our collaboration with the heart failure team, attending MDTs to develop effective management plans that consider both specialties and patient values.