In this insightful interview, Amanda shares her remarkable career journey from being a newly qualified staff nurse to becoming a specialist HF nurse. She sheds light on the challenges she faced in chronic heart failure care, the pivotal role of accurate patient coding, and her current role as the Lead HF Nurse Specialist at Oberoi Consulting.
Professor Ahmet Fuat: Amanda, can you share your career journey to becoming a specialist HF nurse with us please, and what is your current role?
Amanda: “Early on in my career as a newly qualified staff nurse on the coronary care unit at Bradford Royal Infirmary I quickly realised where my sub speciality was: chronic heart failure. Seeing regular faces being readmitted, spending endless nightshifts listening to patients about how it felt not being able to breath; experiencing heavy painful legs, intense itching, unrelenting tiredness, feeling like a burden and not been able to walk to the toilet on the ward…I felt I had to attempt to make a difference to these human beings.
I joined the Bradford HFNS team and completed further heart failure education at the Glasgow Caledonian University and my independent prescribing qualification at the University of Sheffield. I owe my primary education and mentorship to Dr Geoff Morrison, Dr Martin Taylor and the Bradford HF nursing team. I moved on to Doncaster where I helped to set up a primary care based service with an in-reach HF clinic to secondary care including a HF patient support group. I was fortunate to go on to join the Hull & East Yorkshire team and become involved in audit and research as well as leading the HF service alongside Prof. John Cleland and Prof. Andrew Clark to whom I am eternally grateful for their continued mentorship and insight!
My current role is with Oberoi Consulting as the Lead HF Nurse Specialist overseeing the delivery of our Oberoi Disease Management Digital Audit Platform for heart failure and therapeutic review service.
This diverse role offers the best of both worlds – continuing to improve care for those with HF through audit and clinical practice. Observing the impact that clinical audit makes and the virtual clinic consultations with patients across UK is immensely job satisfying. The ability to show case our successes in case studies and research publications is the cherry on the iced cake!”
Professor Ahmet Fuat: In your experience, what are some common challenges or issues related to patient coding on heart failure registers?
Amanda: “Some of challenges include correspondence within the clinical letters received from secondary care; some do not always directly use the terminology heart failure or describe echo findings specifically enough to code from. Secondary care clinic letters and discharge summaries are not always specific enough to aid primary care code patients accurately. Oberoi offer education to both sectors to help highlight the problems occurring within both areas.
What I often find is those on the heart failure register do not have the type of heart failure coded (for example, echo shows left ventricular dysfunction/Heart failure with reduced ejection fraction)
Without the type of HF coded clearly patients may miss out on medication optimisation.
Conversely, if patients who have had their echo findings reported, for example, echo shows LVSD but are not coded as ‘heart failure’ in addition, they will not be listed on the actual HF register and thus miss the practice annual review process. Another key challenge can be choice of code used for ventricular dysfunction; many practices assume ‘impaired ventricular dysfunction’ will suffice; however, this is not specific enough. I spend a lot of time recoding these patients.
I think in general; practices do not receive training specifically on heart failure coding and how to manage these patients. Part of my role is to re-addressing this balance and leaving a legacy in the practice I am working with.”
Professor Ahmet Fuat: How do inaccuracies or omissions in patient coding affect the management of heart failure cases in our practice?
Amanda: “Inaccuracies and omissions can lead to missed patient reviews, medication optimisation opportunities and financial losses under the practice QOF scheme.”
Professor Ahmet Fuat: Can you share an example or scenario where you encountered a patient who was not properly coded on the heart failure register, and how did this impact their care?
Amanda: “Yes, these are common place in reality, I would urge every practice to validate and audit their heart failure registers. One patient in particular springs to mind, this patient had an echo which had not been added to the clinical information system, the heart failure episode had not been added either. The record came up in one out searches from the Oberoi Digital Audit Platform for HF as a potentially missed case.
After looking at the record, I noted that the patient had a previous episode of HFrEF – after coding appropriately, the patient was invited to a clinic consultation and the necessary follow up arranged. Ultimately, the patient had been lost within ‘the system’.“
Professor Ahmet Fuat: What methods or tools do you use to identify patients who may be missing from the heart failure registers or whose HF type may not be correctly coded?
Amanda: “I use the Oberoi Digital Audit Platform for HF which includes a suite of searches which robustly identify patients who are on the HF register who are missing a sub category code (type of HF) and those that have a sub category code who are not listed on the HF register.
The searches sit within the practice’s clinical system which means no added software is added to the GP system. As patients are actioned, the searches can be re-run live within the system to produce new lists”
Professor Ahmet Fuat: How does our healthcare system address the issue of under-coding or misclassification of heart failure patients, and what improvements have you observed over time?
Amanda: “Being brutally honest, I don’t think the current healthcare system currently addresses this issue. I feel it is somewhat reliant upon those members of the team who recognise the importance of accurate clinical coding and how that can impact on the patient’s journey and outcome. HF champions are the ones driving this message loud and clear and our healthcare system needs to recognise the importance of the heart failure patient journey from the outset”
Professor Ahmet Fuat: What role can technology play in aiding your efforts to identify and rectify coding discrepancies in heart failure patient records?
Amanda: “Technology has a fundamental place in conducting clinical audit and clinical coding; without it, my work would take much longer and increase scope for missing cases that may hide from first glance view within a patient’s record. Using the Oberoi Disease Management Digital Audit Platform leaves no stone unturned!”
Professor Ahmet Fuat: In your opinion, what can be done to further enhance our approach to patient coding for heart failure, ensuring that no patient is missed or misclassified, and that their management is optimised?
Amanda: “Specific training on clinical coding for heart failure should be made available and accessible to primary & secondary care teams. What would help this greatly is if NICOR who instigate and manage the national audit for HF (HFNA) become involved and lead the auditing of primary care; this way, both services have a common goal and communication vessel moving forwards.
Once records are accurately coded, the annual recall system for heart failure patients requiring their HF and HF medication review will become more specific and easier for the clinician undertaking the review.
The HF review needs to be more than a tick box exercise; it needs to be one that actively reviews the patient with heart failure with reduced or normal/preserved ejection fraction systematically including consulting the treatment guidelines and documenting why medications have not been optimised or initiated. Accurate coding is the gateway to ensuring we management patients with heart failure appropriately as they so deserve.“