Project Name: Grampian Heart Failure (HF) In Reach Nurse

Project Summary:

  • The main objective of this Collaborative Working Project (CWP) is to improve the quality of care delivered to HF patients under the care of CW Partner, in line with 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure.
  • The objective is to deliver a CWP to improve awareness, identification, management and outcomes for patients with HF in NHS Grampian following an unscheduled admission for HF, both known and de-novo HF patients.
  • This CWP will involve updating the local guidelines to reflect the latest ESC-HF guidelines, then the improvement of the current hospital-based specialist HF service at NHS Grampian, residing at Aberdeen Royal Infirmary, through the deployment of an “in reach” HF nurse specialist with the purpose of:
    • Identifying and triaging HF patients (both at acute medical receiving units, cardiology and non-cardiology departments) so the patients can be appropriately referred to the relevant cardiology service and receive specialist HF input,
    • Coordinating the discharge of patients and liaising with community HF teams, including primary care, to ensure continuous appropriate care for HF patients after their discharge from hospital.
  • Additionally, the CWP aims at establishing a case for future funding of the HF service by NHS Grampian. This will help to  reduce the waiting times for HF out patient appointments and address the high level of unscheduled HF admissions by increasing the input of the cardiology team during these admissions and standardise the follow-up of patients post discharge.

Expected Benefits:

Anticipated benefits for Patients

  • Improved access to evidence based treatment;  
  • more equitable and consistent care and access to care.  
  • enhanced experience for patients and their carers who live with HF. 
  • Increased access to Education on heart failure will enable patients to self manage their condition
  • A personalised heart Failure care plan will help the patient to self manage their condition

Anticipated benefits for the CW Partner

  • Increase the overall quality of care and improve equity of access to specialist care for patients with HF; 
  • Increase proportion of patients with HF being managed in accordance with the ESC 2021 chronic heart failure guidelines 
  • Reduction in waiting list times  

Anticipated Benefits For Novartis

  • Further opportunities for the appropriate use of cardiology licensed medicines in line with NICE guidelines, including Novartis’s medicine; 
  • Improved reputation; 
  • Improved professional and transparent relationship and trust between Novartis and the NHS 

Start Date & Duration: December 2022 for 18 months (12 months clinical activity)