Community Direct Access Service for Early Detection and Treatment of Clinical Deterioration: Effectiveness and Impact on the Workload Pattern of a Hospital-Based Heart Failure Unit

Introduction: The number of patients entering a heart failure program at the heart failure unit at St Vincent's University Hospital (Dublin, Ireland) is increasing. However, the impact of a community direct access service on the workload pattern of a heart failure unit and its appropriateness remain poorly described. The workload of this hospital-based heart failure unit was analyzed over a 3-year period to assess changing workload patterns and to examine the appropriateness and outcome of patients' direct access to the unit. Methods: Clinical audits from the heart failure unit for the years 2002, 2003, and 2004 were reviewed, and the types of visits were classified and expressed as a percentage of total patient contact. A prospective, observational study was designed to examine the volume and nature of community direct access to the heart failure unit. Unscheduled contact was defined as a telephone call to the heart failure unit from a patient or carer seeking advice and/or reporting clinical deterioration. All unscheduled contact was triaged by a heart failure clinical nurse specialist, and advice was given on what to do, including immediate same-day referral to the heart failure clinic (termed an unscheduled visit). Results: Twenty-eight percent of all unscheduled contacts resulted in an unscheduled visit to the unit. Eighty percent of unscheduled visits to the unit demonstrated evidence of clinical deterioration confirmed by physician examination. Eighty-nine percent of patients with clinical deterioration required an increase in oral medications, 10% required administration of an intravenous diuretic, and 1% required direct hospital admission. Unscheduled visits to the unit account for 20% of all clinical reviews annually. None of the unscheduled contacts that were resolved over the telephone (47%) or referred to the family physician or emergency department (25%) resulted in an admission with heart failure. Conclusion: This study underlines the necessity for, and efficacy of, a community direct access service for heart failure patients in redirecting the course of clinical deterioration.