A team at the Cape Breton Regional Hospital (CBRH) can be credited with improving its health standard mortality ratio (HSMR) from one of the worst in the country in 2017 to better than the national average. This was no small accomplishment, but the benefit translates to greater outcomes and longer lives, for those living with heart failure.
When cardiologist Dr. Paul Morrison began working at the CBRH in 2017, the cardiology department began exploring some of these issues behind a health standard mortality ratio that lagged behind the country to determine what could be done to improve outcomes.
“Dr. David McFarlane, my colleague in cardiology, took a leadership role and built a team that was supported by two medical residents and two nurse practitioners (NP). Together, they completed an extensive review to find out any barriers to care and if the deaths were caused by heart failure or something else,” said Dr. Morrison.
The team found that most patients who died of heart failure had never seen a cardiologist during their hospital stay. This data not only encompassed the CBRH but was also an issue for inpatients at other facilities throughout Cape Breton. Many of these patients were not referred to CBRH to see a cardiologist. It was also revealed that many of the patients with known heart failure were not on optimal medical treatments or did not receive echocardiography and brain natriuretic peptide (BNP) testing which is a simple and objective measure of cardiac function.
“We met as a group with the results of that audit and asked, ‘what can we do better,’” explained Dr. Morrison.
Moving forward, the team agreed to reserve spots every day in the echocardiography lab for urgent patients from Nova Scotia Health’s peripheral sites. The purpose of this change was to improve urgent access to echocardiography and clinical review by a cardiologist.
CBRH acquired three new echocardiogram machines which were funded through the Cape Breton Regional Hospital Foundation. This improved access to diagnostics greatly and helps inform the best treatment pathway for each patient.
The team also conducted education sessions for the family doctors and nursing staff at peripheral sites.
“The education sessions emphasized that heart failure patients need to be referred to a cardiologist more quickly,” said Dr. Morrison. “I think the education sessions were appreciated by community groups and they made a difference that we're still seeing today. We are getting more phone calls from physicians in the community about their patients, which is exactly what we wanted.”
Referral wait times were previously between six months and two years. Dr. Morrison said this waiting time caused missing opportunities to get people on the right track more quickly. This led the team to engage the pharmacy company Novaris. Novaris, which makes the popular heart medication Entresto, funded the establishment of a new heart titration clinic which allowed the cardiology team to see patients and start treatment more quickly.
A preliminary review of clinical visits for six months of operation showed that 84 per cent of patients were receiving goal-directed therapy for heart failure, which represented a significant improvement.
Dr. Morrison attributed the improvement to better implementation of the Canadian Cardiovascular Society Heart Failure Guidelines. As per the guidelines, most heart failure patients should be seen every two weeks with a goal that within 90 days they are on full goal-directed therapy.
This work, in total, showed an overall improvement in HSMR 123 (2019-20) to 108 in 2021-22. But, for the patients, what this means is a longer life expectancy and better outcomes for those living with heart failure. There is no number available to measure the quality of those additional days that a patient gets to experience with their family and loved ones.
“We didn’t reinvent the wheel; we just found a way to achieve that goal,” said Dr. Morrison. “We are very proud of this work.”
Originally separate from Nova Scotia Health during the pilot, the titration clinic is now incorporated into the heart function clinic at the CBRH.
The team also hired one additional NP dedicated to cardiology in the Eastern Zone. This increased the number of NPs dedicated to cardiology from three to four as of November 2022. NPs not only provide essential patient care and access, but also patient and family, and staff education and care support to the cardiac team.
Dr. Morrison said the cardiology team’s success has generated a positive momentum, “you don’t have to be a major academic institution to be innovative and positively change care.”
