Dr John B Pittard, a general practitioner in Staines, comments on whether implementing these research findings is achievable in primary care
The Sheffield audit of heart failure discharge advice given to GPs by Kanaan, Bashforth and Al-Mohammed (see pages 113–16) illustrates perfectly the imperfections of implementing research findings and guidelines into every day clinical practice. The paper rightly points out the selective nature of the entry criteria of patients to RALES (Randomised Aldactone Evaulation Study).1 Most research trial patients are more scrupulously managed and monitored than in real world circumstances. The traditional way of organising discharge summaries usually defaults to the least experienced junior staff. The perception is often that a career in accountancy would be more exciting than this task.
The majority of hospitalised chronic heart failure (CHF) patients will be elderly, with challenging personal fitness and domestic circumstances. Most will be New York Heart Association (NYHA) grade III/IV with imperfect renal function aggravated by use of angiotensin-converting enzyme (ACE) inhibitors/antiotensin receptor blockers, diuretics and perhaps spironolactone. With assiduous medication supervision, many will enjoy some digitalis and beta blockers as well. Advice from the National Institute of Health and Care Excellence (NICE) to monitor bloods at weeks one, four, eight and 12 is easy to generate in a comfortable conference room before lunch by well meaning folks who will rarely call in at home of a grade IV CHF patient. It is certainly reasonable to add this advice in a one-line summary on the discharge letter. Perhaps a better way would be to have a template default letter generated by computer to be routinely added to the CHF patient discharge to the GP, rather than around a quarter of all letters failing to mention this.
In the community these high maintenance CHF cases are best shared by GPs and specialist heart failure nurses. The majority of contacts will be where these patients reside. The question of home visiting and access, then successful venesection and delivering samples in the first half of a ‘9 to 5’ day at a local laboratory takes on the logistical challenge of a NASA moon programme. The withdrawal for many patients of a home support service for such testing has occurred with the fragmentation of the provider services; many of whom win contracts by reducing services and employing fewer staff. There are many examples of good practice such as community matrons, virtual wards and some practices managing to fund home blood testing. For others a modified NICE guideline such as monitoring at one, six and 12 weeks might be better than currently is offered.
Ideally the discharge advice can have NICE monitoring guidance as a computer generated addendum. Clinical commissioning groups might explore local solutions to feasible testing provision for these CHF patients. They certainly generate excessive hospital costs if readmitted with electrolyte and drug concordance issues.The improvement in day-to-day well being with well-managed CHF patients remaining at home is every bit as important as the postulated survival benefit. Personally, I cannot recall a death certificate in 30 years that mentioned hyperkalaemia.
John B Pittard
Chertsey Lane Surgery, 5 Chertsey Lane, Staines, TW18 3JH
1. Pitt B, Zannad F, Remme WJ, Cody R et al. for the Randomized Aldactone Evaluation Study Investigators. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. N Engl J Med 1999;341:709−17. http://dx.doi.org/10.1056/NEJM199909023411001