“Failure to Function - A review of the care received by patients who died in hospital following an admission with acute heart failure” is the latest contribution to quality improvement in patient outcomes from the National Confidential Enquiry into Patient Outcome and Death (NCEPOD).
The reviewers examined the records of 402 patients with a diagnosis of acute heart failure (AHF) who died within 7 days of admission. The diagnosis was often made late owing to non-specific presentation. With a median age of 82 years the patients presented with significant co-morbid disease. Frailty and pre-morbid New York Heart Association (NYHA) class were a major feature; 72% were moderately frail or worse (Rockwood clinical frailty score 6 to 9) and 34% were NYHA class IV.
127 (28%) of patients were referred to critical care. 55 were not admitted and of the 72 who were, only 40 were cared for in a level 2/3 environment with the majority going to a coronary care unit. Only one fifth of those who had a Karnovsky score of 50% or less (requires frequent assistance or medical care or worse) were referred to ICU. Notably the reviewers identified 31 (15%) cases where ICU input was indicated but did not occur and strikingly only 33% of patients were reviewed by a specialist heart failure team with less than half being seen by a cardiologist prior to death.
So what have we learnt, and what can the intensive care community do to support the implementation of the recommendations of this report?.
First, an assessment of frailty and pre-existing functional status, should continue to influence our decision-making regarding the likely benefit of critical care. Second, in line with both the recommendations from this report and the Guidelines for the Provision of Intensive Care Services (GPICS), immediate engagement of (specialist) cardiology and their continued involvement in patient care on the ICU should be a priority. We must not underestimate the added value of cardiology input into these cases, specifically when interventions such as angiography, heart rhythm management or structural heart interventions may dramatically alter patient trajectory. Third, we should continue to support appropriate and active decisions regarding escalation of care and involvement of palliative care using frailty and premorbid functional status and quality of life as reasonable indicators of likely benefit. Finally, given that only 44% of those with a new diagnosis of AHF had echocardiography, there may be the opportunity for us to leverage the increasing experience and formalised competency of transthoracic echocardiography within the UK ICU community. Images should be captured, stored and reported on admission for all patients with AHF by appropriately trained staff in line with GPICS / British Society of Echocardiography recommendations to facilitate either local or remote discussion with specialist cardiology.
So, whilst perhaps not as impactful from an ICU perspective as previous reports, it serves as a timely reminder that, whilst we should play to our ever-broadening strengths and skills as intensive care practitioners, we need to engage and welcome specialty team input at an early juncture in all patients but specifically those at high risk of death.
Alastair Proudfoot. December 2018.