Early intervention in acute heart failure

Purpose

Acute heart failure (AHF) is the most common cause of admissions for patients aged 65 and over in the UK. The occurrence of functional decline in elderly adults with hospitalisation for acute illness is well established with decline occurring as early as day two of admission.

With an average length of stay of 18.7 days, patient age of 71.4 years, and 77.1 per cent of patients having at least one other chronic disease, those admitted to the heart failure unit at St George’s Hospital are high risk for functional decline throughout their stay.

Traditionally these patients would not be seen by a physiotherapist until after their intravenous diuretic treatment was completed. The aim was to assess the impact of early and specialist physiotherapy assessment and intervention on functional decline during hospitalisation of patients with AHF.

Approach

The Elderly Mobility Scale (EMS) was used to assess mobility on both admission and discharge from the heart failure unit. Patients were provided with individualised physiotherapy intervention while an inpatient, aimed at preventing functional decline, planning for discharge, and promoting rehabilitation and self-management.

Admission and discharge EMS scores for patients admitted between March 2016 and October 2017 were compared. Patients who passed away, transferred for onward medical care, or who were at the ceiling of the EMS on both admission and discharge were excluded. 153 sets of data were compared in total. Details on admission date to first assessment by physiotherapy were collected.

Outcomes

• The median length of stay was 10.0 (range 1-72) days.
• Patients waited for physiotherapy on average less than 24 hours (range 0-7 days).
• Patient EMS scores increased significantly (p < 0.001) from admission (Median 14.00: IQR 11.00-18.00) to discharge (Median 16.00: IQR 13.00-18.00).
• Seven patients (5 per cent) had a decrease, 74 patients (48 per cent) showed no change and 72 patients (47 per cent) had an increase in their EMS score on discharge compared with admission.

Change in functional outcome from admission to discharge

The EMS categorises patients into dependency levels based on score achieved.

• For dependent patients (EMS 0-9, n=30) on admission the median EMS score changed from 5.0 to 12.5.
• For borderline category patients (EMS 10-13, n=42) median EMS changed from 12.5 to 13.0.
• Patients in the independent category on admission (EMS 14-20, n=81) had no change in their median admission EMS score of 18.0.

On admission 20 per cent of patients were in the dependent category. This reduced to 6.5 per cent on discharge. Patients categorised as independent increased from 53 per cent to 71 per cent.

Top three learning points

1. Early physiotherapy intervention prevents functional decline and reliance on community services
2. High risk patients benefit the most from early physiotherapy intervention
3. Physiotherapy is beneficial for patients hospitalised with acute heart failure

Implications

• Patient benefits - improved quality of life for heart failure patients, particularly those at high risk of functional decline
• Social benefits - reduced reliance on care services in the community
• Work force planning - commissioning of physiotherapy establishments for new and evolving heart failure services

Author’s reflections

Completing this project has allowed me to demonstrate the substantial benefit of early and specialist physiotherapy input in an area currently undergoing service expansion throughout the UK. I have had the opportunity to present this work at both national and international conferences including Physiotherapy UK 2018 and the WCPT Congress 2019.

My advice for anyone planning to complete a similar project is to consider your stakeholders and use the expertise of the team around you. This will be an invaluable resource to help formulate your question and present your findings.

Notes and funding

• This work was unfunded
• This work was presented at Physiotherapy UK 2018

For more information visit Susan’s database entry

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