Before a patient is discharged from the hospital, CGH uses a stratification model that calculates his or her risk of heart failure-related readmission. Based on the findings, patients are offered a co-management follow-up programme with primary care providers — currently Pasir Ris Polyclinic or the Tampines Family Medicine Clinic — to facilitate early symptom reviews within one to two weeks after their discharge. This helps in the optimisation of their personalised therapies for heart failure and management of their comorbidities like hypertension and diabetes.
These early follow-up reviews have helped to decrease patient readmission rates at the hospital. “We have plans to expand this programme and collaborate with more outpatient clinics,” says Ms Angela Ng, Senior Manager, CGH Health Management Unit (HMU). “Patients will thus have more options to choose from for their follow-up care, allowing for timely reviews for their condition and early interventions.”
To enable continuity of care for patients after their discharge, CGH established a Structured Telephone Support (STS) service in 2011. Initially customised for diabetes patients, the STS was subsequently extended to chronic obstructive pulmonary disease (COPD), heart failure and patients with other chronic conditions.
Provided by CGH’s HMU as part of the CGH heart failure pathway, the STS for heart failure patients consists of structured phone calls over a 12-week period at pre-defined intervals. Through the STS, telecarers — who are senior staff nurses at CGH — help to support heart failure patients in the community. The telecarers monitor patients’ conditions and advise them on diet and lifestyle adjustments. Through the regular calls, the telecarers reinforce patients’ knowledge of heart failure and familiarise them with the signs and symptoms of deterioration. The telecarers are supported by CGH’s multi-disciplinary team of specialists, trained nurses, medical social workers and allied health professionals. Where necessary, they are also able to escalate the situation to the hospital’s emergency department.
CGH patients on the heart failure pathway are automatically enrolled in the STS service. “Through this personalised service, patients are empowered with the necessary knowledge, skills and support that enables them to better manage their condition in the community,” says Ms Ng.
CGH’s cardiac physiologists carry out procedures such as echocardiograms, an imaging scan used to look at the heart.
Capturing one’s heart
Cardiac physiologists — who start off as cardiac technologists — are AHPs specialising in heart health.
“We perform investigative procedures and analyse the results to help cardiologists diagnose heart diseases,” shares Senior Cardiac Physiologist Xiao Yawei about her role. “I carry out cardiac ultrasound scans (echocardiograms) for patients in clinics and wards, using ultrasound machines.”
An echocardiogram is an imaging tool used to look at the heart and nearby blood vessels. High-frequency sound waves are used to take images of the heart and its related structures, which show the size and functionality of the various body parts, as well as the efficiency of the contraction of heart muscles and blood flow across the valves.
“During the scans, with my understanding of the human heart, I determine whether the heart structure seen is normal, and adapt my scan investigation accordingly,” she explains. The final test result is then used by the cardiologists to decide on the treatment for the patient. For emergency cases, Ms Xiao ensures that the echocardiogram reports are conveyed to the primary care team as soon as possible.
A stress echocardiogram test is performed on patients who exhibit heart symptoms when they engage in exertive activities. During the stress test, Ms Xiao works together with CGH echocardiologists and nurses to scan and monitor patients’ symptoms while they are physically stressed, or when taking medications.
Going the distance with patients
Ms Xiao’s work also involves conducting regular follow-up scans for patients with heart failure to assess their heart function over time, or when their symptoms worsen.
For patients with poor heart function, a pacemaker may be implanted just below the collarbone to improve their heart function as part of cardiac resynchronisation therapy (CRT). After the CRT implant, patients have to have their devices checked regularly by cardiac physiologists. Ms Xiao performs these follow-up
checks on the device’s battery status, performance and the detection of any abnormal heart rhythms. The collated information is then reviewed by a cardiac electrophysiologist to help them formulate or update the patients’ care plans.
Cardiac physiologists also perform electrocardiogram (ECG) tests to help in the diagnosis of atrial fibrillation. The ECG provides information on how fast or slow a patient’s irregular heartbeat is. Patients with overly-slow heart rates might require a pacemaker. Similarly, Ms Xiao conducts regular checks on these devices, and — together with a cardiac electrophysiologist — optimises their performance as necessary.
Cardiac Catheterisation Laboratory (CCL) is a procedural area that provides both diagnostic and interventional cardiac procedures for patients. All procedures performed in the CCL are done under fluoroscopy guidance. A fluoroscopy examination uses a continuous stream of X-rays to enable the cardiologists to diagnose, evaluate and render treatments accordingly. Diagnoses, evaluations and treatments can be carried out at the CCL for cardiac conditions. These include procedures such as left and right heart cardiac catheterisation, percutaneous coronary intervention (PCI) and cardiac device implantation.
Following their heart’s calling
Carrying out these procedures in the CCL is CGH’s multi-disciplinary team of nurses, cardiologists, radiographers and clinical physiologists. Among the cardiologists, doctors known as electrophysiologists specialise in diagnosing and treating abnormal heart rhythms, and performing cardiac device implantations.
The nurses at the CCL coordinate procedural schedules and ensure the availability of consumables to support daily operations. “The nurses also perform scrub and circulating roles in assisting the cardiologists in the cardiac implant procedure, render emergency responses and operate adjunctive machines,” says CGH Nurse Clinician Sasikala Doraisamy. CCL nurses also educate patients on self-care following the implantation of the cardiac device.
Caring for patients in the hospital
Inpatient nurses at the cardiology ward play an essential role in rendering bedside care for patients with heart failure. They monitor patients’ body weight, fluid intake and urine output closely as such data is crucial for their daily treatment plan. Patient education on the restriction of fluids, adopting a low-sodium diet and lifestyle modifications are key components of overall management and help to reduce readmission rates.
In the wards, patients with arrhythmias are placed on a cardiac telemetry device. Nurses use this to monitor their heart rhythm 24/7 at a central monitoring station and are able to raise alerts to the care team when life-threatening heart rhythms are detected.
CGH inpatient nurses also collaborate with the AHPs and heart failure case managers — a role undertaken by the nurses — to strengthen the knowledge imparted to patients and caregivers, and encourage patients who are medically stable to stay active and optimise their nutritional intake. Besides administering prescribed medication, the nurses also offer emotional support to patients who experience strain on their emotional health.
A CGH nurse takes the weight of a patient with heart failure using a chair-weighing scale.
A CGH nurse monitors patients with irregular heartbeats at the central telemetry monitoring station.
Nursing patients in the community
To ensure a seamless care transition from hospital to home, the heart failure case managers develop a discharge plan with patients and their families, communicating and coordinating care beyond the hospital as part of the CGH heart failure pathway.
For patients who return for their follow-up appointments at the CGH Heart Failure Clinic, the case managers provide nursing assessments, and conduct and reinforce health education. If the nurses identify potential clinical and psychosocial needs, they are also able to make appropriate referrals.
CGH case managers share health information on heart failure with a patient at the CGH Heart Failure Clinic.
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