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Advanced heart failure outpatient clinic

The advanced heart failure outpatient clinic will be dedicated to patients with severe left ventricular systolic dysfunction (FE < 30%), symptomatic (NYHA class greater than IIa), reduced functional capacity (assessed by cardiopulmonary test or six minute walking test) recent hospitalisation (first diagnosis of heart failure or exacerbation of heart failure with congestive phenotype or with clinical signs of low flow rate or sustained ventricular arrhythmias) and will be referred by the Foundation’s internal or external physicians with a view to undertaking a course of close clinical and instrumental follow-up and with the plan to be promptly referred to the transplant/left ventricular assist pathway, if possible.

The discharge of patients with advanced HF from hospitals is currently considered a “difficult discharge”; in this regard, our project provides for an ad hoc discharge with the presence of the ward doctor, the dedicated nurse and the caregiver to better illustrate the clinical picture that emerged during hospitalisation and build the patient’s subsequent diagnostic-therapeutic pathway; in the pre-discharge phase it is essential to establish a continuity relationship with the treating doctor and, where necessary, with the local nursing services.

At the advanced HF outpatient visit, all patients will undergo a comprehensive assessment (with an integrated approach of the cardiologist specialist, dedicated nurse, physiotherapist) carried out on the day of first access. Based on the results of the initial assessment, any further instrumental investigations will then be scheduled, any need for hospitalisation will be indicated and the next clinical and instrumental follow-up will be planned.

Overall plan

Outpatient frequency: once every 2 weeks.

From 8:30 am, the three patients will undergo, at 30-minute intervals, the joint nurse-physiotherapist assessment (specified below); then the first cardiological visits will be carried out from 10:00 am to 1:00 pm in the presence of the caregiver.

At the end of each first visit, an interview will be held between the patient, the caregiver and the multidisciplinary team with the issuance of illustrated information brochures. At the first visits of patients referred by other facilities or by other FTGM clinics, the following questionnaires will be carried out: Kansas City Cardiomyopathy Questionnaire (KCCQ) for the patient, Zarit Burden Interview (ZBI) for the caregiver (repeated after 1 month and then every 6 months). For patients who have already been admitted to our hospital, a service for completing the questionnaires (sent by email or SMS) is already active at discharge. Here again, this is re-assessed at 1 month and then every 6 months.

From 1:15 pm to 3:30 pm, two cardiological check-ups will be carried out, with the possibility of activating the multidisciplinary evaluation on a case-by-case basis.

             1. Initial diagnostic assessment (first visit)

From 08:30 am to 10:00 am (dedicated nurse-physiotherapist)

  • assessment of vital signs (BP, HR, SpO2) and body weight;
  • blood tests (blood count, creatinine, electrolytes, liver function, coagulation, HS troponin T, NT-proBNP, sST2, LDH, AST, ALT, gammaGT, total bilirubin)
  • baseline electrocardiogram or PM check if necessary (poss. shock of the device)
  • recovery of remote PM/ICD monitoring data (for patients who have one)
  • in patients with an LVAD, perform driveline dressing and check the alarms
  • nursing counselling: lifestyle, adherence to dietary and behavioural rules, compliance with therapy, critical issues in patient management, patient-caregiver relationship
  • functional assessment performed by the physiotherapist

On a case-by-case basis, any visits with the aforementioned specialists will be planned at facilities outside the foundation.

In order to establish the appropriate timing of the cardiological follow-up, we proposed the creation of a dedicated e-mail (scompenso@ftgm.it) and the initiation of serial telephone follow-up by dedicated nurses, also with the aim of providing a system of direct communication between the patient and the advanced outpatient clinic. This follow-up will take place once a month (30 days after outpatient visits or 30 days after hospital discharge, possibly modified on a case-by-case basis).

             2. Initial diagnostic assessment (subsequent check-ups)

From 1:45 pm to 4:00 pm – three check-ups every 45 minutes with a cardiological and nursing visit. Any need for the presence of the family member/caregiver will be decided on a case-by-case basis.

The check-up visit includes

  • assessment of vital signs (BP, HR, SpO2) and body weight;
  • baseline electrocardiogram or PM check if necessary (poss. shock of the device)
  • in patients with an LVAD, perform driveline dressing and check the alarms
  • check-up echocardiogram

In the event of clinical/instrumental worsening, hospital admission will be planned to perform a course of intravenous diuretic therapy, possible treatment with inodilators, the need for a right catheterisation, the initiation of the pathway for eligibility for implantation of a left ventricular assist device or re-evaluation at the Transplant Centre. In patients with a LVAD who experience clinical worsening, hospitalisation is recommended to rule out any complications related to the mechanical assist device (pump thrombosis, bleeding, infectious problems, etc.).