Introduction Ambulatory management of heart failure has reduced the number of inpatient admissions and the cost of management. However, the practice of frequent clinical reviews (2–3 times per week) in the Acute General Medicine (AGM) – led Same Day Emergency Care (SDEC) unit had become burdensome for a patient cohort that tends to be frail and multimorbid. Additionally, the shared care between AGM and the Heart Failure Team (HF team) led to uncertainty regarding who would review and be responsible for patients attending the SDEC with heart failure. Evidence suggests that hospital-initiated case management helps to reduce unplanned admissions for heart failure. This project intends to streamline the delivery of ambulatory heart failure management and improve the interface between AGM and the HF team through the implementation of a collaboratively led multidisciplinary team (MDT) meeting.

Aims and objectives of the research project or activity The aim of this quality improvement project was to restructure our heart failure service and implement a weekly MDT meeting to review the progress and care of patients under the ambulatory pathway. The purpose of this MDT is to reduce the need for patients to return to the SDEC for clinical reviews; thereby increasing the delivery of treatment and clinical reviews at home. For patients who do require further face-to-face encounters, the MDT meeting provides an opportunity to clarify the purposes of that encounter. This allows for appropriate clinical and logistical planning to take place, thereby reducing the number of additional encounters and the amount of time that patients spend on the unit. Secondary aims included improving patient experience, understanding the interface between AGM and the HF team and fostering good communication between the various stakeholders managing heart failure patients.

Method or approach A weekly MDT meeting was introduced from October 2022. At minimum, the MDT consisted of a Heart Failure Advanced Nurse Practitioner (ANP), a pharmacist, an AGM doctor and the SDEC Charge Nurse. The patient list would be compiled and presented by the Heart Failure ANP. The patients’ progress would be reviewed from the Hospital at Home (H@H) documentation or telephonically if the documentation was not available or further clarification was necessary. The metrics reviewed would be the patient’s symptomatology, vital signs, weight, level of oedema and renal function. The patient’s current diuretic regimen and prognostic medications would be reviewed and any necessary adjustments made during the meeting. The pharmacist would then dispense any new medications which would be delivered at the next home visit or via a courier. Should a return encounter have been deemed necessary, plans for transport, investigations, management and consultations were co-ordinated by the MDT.

Findings Between October 2022 and November 2023, 58 MDT meetings have been conducted and 179 patients who were under 3 different H@H teams have been discussed. Each week, the MDT have reviewed up to 12 patient cases.

Since November 2021, the Oxford-based H@H team have administered 2537 doses of Furosemide intravenously for 332 patients. The total amount of diuretic administrations per quarter in 2023 are consistently higher than in 2022.

This data is a reflection on both the growth of the service and a shift in practice towards treating heart failure in a predominantly non-clinical setting. It shows that we are increasing our delivery of diuretics at home.

A review of cases discussed in the MDT over the course of one month revealed that 64% of the patients had active medical issues (in addition to a diagnosis of heart failure) that required the input of a general medical doctor. This confirmed the need for the service to be delivered by AGM with specialist consultation services provided by the HF Team.

Data gathering is still underway to evaluate the broader impact of this project including calculating the number of return visits to the SDEC.

Key messages Introduction of the MDT has been a collaborative, multidisciplinary solution to streamline the delivery of ambulatory heart failure management while continuing to ensure the delivery of safe ambulatory care. The model has transitioned through various iterations while developing an understanding of what each of the members’ roles should be and what could be achieved. It provides an opportunity for shared decision making and has improved the interface between AGM and the HF Team. Patients with decompensated HF require regular monitoring during treatment and these encounters would have otherwise occurred as inpatients or in urgent specialist outpatient clinics; both of which are limited resources. The MDT provides cohesive oversight for heart failure management across both clinical and non-clinical settings and is working to encourage the move towards delivering management in a predominantly non-clinical setting.