New Cape Breton clinic aims to improve survival rate after heart failure

After having the worst death rate in the country for three years running, Cape Breton hospitals are dramatically improving the number of patients surviving heart failure.

Dr. David McFarlane, a member of the cardiology team at the regional hospital in Sydney, said staff took matters into their own hands earlier this year and reviewed the charts of all those who died unexpectedly from heart failure in hospital over the past three years.

They were surprised to find that 75 per cent were never seen by a member of the cardio department.

In some cases, that's because the patients were at smaller community hospitals in New Waterford, Glace Bay and North Sydney, he said, but for the most part, it was because there were too many patients and not enough doctors and nurses.

"Through just the sheer volume of patients that we have to see, we were just not really able to see all of them," McFarlane said.

The team also found that followup was not being done. Instead of seeing patients a couple of weeks after discharge, it sometimes took up to a year.

Nurse practitioner added

"[It's] important because when people leave hospital with heart failure, they tend to be in their most fragile phase," McFarlane said.

"Now no one's watching over them on a day-to-day basis, and it's also very important to try to increase their medications as quickly as possible for them to have the better outcome."

McFarlane said Nova Scotia Health has since added a nurse practitioner to the cardiology team to ensure each patient who has heart failure in hospital is seen. He said the cardiology department got funding from pharmaceutical company Novartis to establish a new clinic to see patients after discharge.

The overall death rate, which is made up mostly of heart failure, chronic pulmonary obstructive disease and sepsis, started to come down at the end of the last fiscal year in March, but the heart failure numbers show a huge improvement in the first six months of this year, McFarlane said.

Figures from Nova Scotia Health show the hospital standardized mortality ratio from heart failure alone at the hospital in each of the last five years was consistently above 100, which is considered roughly the national average.

In 2016-17, it was 126 and in subsequent years, it was 245, 138, 164 and 115.

From April to September 2021, the heart failure rate was 72. That means more people survived who would otherwise be expected to die.

McFarlane said it's not just that lives are being saved.

"Irrespective of the numbers, we can tell that there's a difference," he said. "They feel much better very quickly. They don't come back to the hospital all the time. They don't feel short of breath and so on. So we definitely see the changes."

It is only six months worth of data, but McFarlane said it is a remarkable turnaround after having the worst mortality rate in the country for three years running.

The cardiologist said normally, patients discharged from hospital are referred to the heart function clinic for checkups.

"In the past, some of these patients that would come out with heart failure, they wouldn't be seen for maybe six months or a year after discharge and that was simply because of a staffing issue," he said.

"We just didn't have the manpower to do it."

New clinic helps adjust meds

So the cardiology team created what it calls the titration clinic, which allows staff to see patients sooner and to monitor and gradually adjust — titrate — their medication.

Sandra Toner, a full-time nurse practitioner with the cardiology department who also works at the titration clinic, said she doesn't mind putting in some overtime to get the new clinic rolling.

"It was an adventure that I knew was going to be a little bit more work, but I thought we needed to take another closer look at how we could treat our heart failure patients differently," she said.

Most heart failure patients show up at the clinic feeling breathless and tired, but Toner said staff are seeing improvements in subsequent visits.

"You will have no idea how it feels to take somebody from a sense of breathlessness, not able to do what they normally can do, and we put them on these evidence-based medicines and they feel better," she said.

Drug company funding

The clinic is funded by Novartis, which pays for office space, supplies, a nurse practitioner's salary and some administrative support.

McFarlane said that means patients are now seen two weeks after discharge and every two weeks after that, until their medication is stabilized.

He also said the pharmaceutical company, which makes the popular medication Entresto, has no say over which medicines are prescribed, and the doctors do not receive any money on top of their fees from the province.

The majority of patients are prescribed Entresto because it is widely recognized as the top medicine, McFarlane said, but others who do not meet the criteria for that drug are prescribed something else.

However, the new clinic is not sustainable, he said, because the nurse practitioner already has a full-time job.

Calling on the province for help

McFarlane is asking the province to fund two more nurse practitioners to allow the new clinic to operate without drug company funding.

No one from Nova Scotia Health was available for an interview, but in an email, Brett MacDougall said the titration clinic is having a "great impact on patients living with heart failure."

MacDougall, executive director of operations in the eastern zone, said the province has recruited cardiologists over the last couple of years and now has a full complement of four in Cape Breton.

It has also hired two more nurse practitioners who are expected to join Toner in the heart function clinic soon and has submitted a budget request to add two more.

"We are currently looking at ways to integrate the titration clinic into the heart function clinic, now that we've increased the number of nurse practitioners in the heart function clinic to three," he said.

"Should funding for the two additional nurse practitioner positions be approved, it would further increase the capacity of the heart function clinic to five nurse practitioners."

MacDougall said with the current focus on the COVID-19 pandemic, it is not yet clear when the additional funding request will be considered.

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