RPM for people with heart failure

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Clinicians can use this guide to enhance care for patients living with heart failure who may benefit from remote patient monitoring (RPM).

It is intended to support clinicians with limited experience managing patients in community settings with one or more chronic conditions, or who may have varying access to primary care services and specialist support.

Use the general patient journey information, together with these specific steps for patients living with heart failure.

What is heart failure?

Heart failure is a complex clinical syndrome with typical symptoms and signs that generally occur on exertion, but can also occur at rest. It is secondary to an abnormality of cardiac structure or function that impairs the ability of the heart to fill with blood at normal pressure, or eject blood sufficient to fill the needs of metabolising organs.

More on heart failure from the Heart Foundation

Patient identification and referral

When determining a patient's eligibility for RPM, take into account patient suitability and alignment with the service model.

Based on clinical judgement and the following criteria, patients with heart failure may be eligible for RPM when they:

  • have a confirmed diagnosis of heart failure. Consider the different types, including:
    • preserved ejection fraction (HFpEF)
    • reduced ejection fraction (HFrEF)
    • mildly reduced ejection fraction (HFmrEF)
  • meet the general eligibility criteria
  • belong to a priority population
  • would benefit from RPM to meet identified healthcare goals specific to heart failure.

Patients with heart failure at higher risk of hospitalisation who may benefit from RPM include those who:

  • have a new diagnosis of heart failure
  • have had a recent (in the past 30 days) hospital presentation/admission for heart failure
  • show deterioration of heart failure symptoms.

Patients with heart failure who have two or more of the following indicators are at an increased risk of premature morbidity and mortality:1

  • Aged over 65 years or over 45 years for Aboriginal and Torres Strait Islander people (noting heart failure can occur at earlier age)
  • New York Heart Association (NYHA) Classification Class III or IV symptoms
  • Charlson Index of Comorbidity Score of ≥ 2
  • A left ventricular ejection fraction of ≤ 30%
  • Living alone or in a location remote from specialist cardiac services
  • Depression
  • Lower socioeconomic status
  • Significant renal dysfunction (glomerular filtration rate <60 mL/min/1.73 m2)

For generalist services providing RPM, consider referring the patient to a specialised cardiac heart failure service (if they have not been referred already) to enhance the care given through RPM.

In addition to the general RPM suitability considerations, use the following key factors to assess RPM's alignment with, and responsiveness to, the clinical needs of a patient with heart failure.

Key factorsConsideration
Type of monitoringCan the service offer the type of monitoring that is needed to manage the patient's condition?
RPM platform capabilities Can the RPM platform collect and present data to track the types of treatment and lifestyle factors relevant to heart failure?
Patient’s present condition and available support Consider whether it is clinically appropriate for the patient to be remotely monitored in a non-hospital setting if facilitating early hospital discharge or hospital substitution. To support this assessment, the admitting clinician should determine the following:
  • Is the patient haemodynamically stable?
  • Has a medical officer reviewed the patient?
  • Does the patient have undiagnosed chest pain?
  • Does the patient or family/carer have the capacity to follow care and escalation plans?
  • Is the patient safe to be at home with existing supports?
  • What is the expected baseline functioning for this patent?
  • Are there defined and current altered calling criteria (ACC) for the patient if required? (Current documented ACC for the patient should be part of the transfer of care.)
  • Is there a current heart failure action plan for the patient?
Goals of care

Review the referral to establish the patient's expected care goals and, where necessary, liaise with the patient prior to onboarding to assess overall suitability for RPM.

Goals of care will be based on the patient's current condition and baseline, the service model capabilities, RPM platform functionality and the patient's preferences.

Onboarding

The below example is a heart failure care pathway that can be allocated to a patient through an RPM platform. A care pathway task, frequency and schedule should be adjusted based on the patient’s individual requirements and clinical need.

Example of a heart failure RPM care pathway

Care task

Type

Frequency (minimum)

Schedule

Default

Blood pressure

Vital sign

Daily

6–11am

Pulse rate*

Vital sign

Daily

6–11am

Oxygen saturation*

Vital sign

Daily

6–11am

Weight

Vital sign

Daily

6–11am

* See Considerations for patient-reported observations.

Optional

Consent form

Survey

Once (optional per LHD)

Onboarding

Survey to review patient wellbeing

Survey

Optional (as clinically indicated)

-

Survey to review heart failure symptoms

Survey

Ad hoc (as clinically indicated)

-

NSW Health has endorsed patient-reported outcome measures (PROMs) that are suitable for patients with heart failure. At a minimum, these should be completed at patient onboarding and offboarding from the RPM service.

These PROMs can be accessed by NSW Health staff through the Health Outcomes and Patient Experience (HOPE) Platform. They include:

  • Patient-Reported Outcomes Measurement Information System- 29 (PROMIS-29): used in adult population to measure the level of concern and their overall wellbeing.
  • Kansas City Cardiomyopathy Questionnaire (KCCQ-12): provides a measure of symptoms and physical limitations associated with heart failure.
  • Partners in Health (PIH) scale: a patient activation measure to be used as clinically indicated where chronic disease management and self-management information forms part of shared decision making.

More about patient-reported measures

Technology

For general information on types of monitoring and devices, see Technology to support RPM.

RPM device selection

Consider the following guidance when selecting RPM devices for heart failure patients.

  • Heart failure patients may have their own monitoring devices, which are unlikely to have the Bluetooth capacity needed by the relevant RPM. If patients are more comfortable with, and prefer to, BYOD, they will need to manually enter their measurements into the supplied tablet or smartphone app.
  • Discuss the patient's and family member or carer’s preferred option both for the period when the care team will be monitoring results, and for ongoing self-management.
  • Educating patients to use their own equipment will support their capacity to self-manage more effectively after discharge from the RPM service.

  • Clinicians should customise device kits to suit their patient's individual care needs and preferences, adding or removing items, as required.
  • The below example is a kit suitable for use with the sample care pathway above.
  • A patient’s comorbidities may also benefit from monitoring. This should be considered when developing the care pathway and creating their device kit.
Warning: Bluetooth devices pose a risk to implantable cardiac devices when placed directly over the chest or within 6 inches/15cm. If applicable, ensure the patient and their family or carer is aware of device placement when taking their measurements.
Heart failure sample kit
Tablet
  • Tablet with cover
  • Tablet charging plug and cable
  • SIM card
Biometric devices
  • Finger pulse oximeter
  • Blood pressure (BP) monitor
  • Weight scales
Accessories
  • Kit protect case
  • Adult BP cuffs (small, medium, or large)
Consider the total weight of the kit, including devices, consumables and case. Patients may require support when receiving, using and returning the kits.

Monitoring and review

Consider the following factors when choosing and scheduling which vital signs to monitor for patients with heart failure.

Observation Considerations for patients with heart failure
Ketones monitoring
  • Consider ketones monitoring for patients who have been prescribed sodium-glucose co-transporter-2 inhibitors (SGLT2i), as they are associated with an increased risk of diabetic ketoacidosis (DKA) that does not always occur with significantly elevated blood glucose levels, making it difficult to diagnose unless the clinician is aware of this risk.
  • The risk of DKA induced by SGLT2-i medications appears to be greatest during acute illness at home or in the hospital (with or without decreased oral intake), or during preparation and fasting for procedures, particularly perioperatively.2
  • Consult with the patient's GP or relevant specialist regarding the discontinuation and recommencement of SGLT2i medication and the need for ketone monitoring.
Blood pressure
  • To guide timing of measurements, follow the Heart Foundation's recommendations to:
    • take morning measurements before breakfast and morning medications, and after 5 minutes in a sitting position. Aim for same time each day
    • take evening measurements before retiring, after medications and after 5 minutes in a sitting position. Aim for same time each day.

  • When postural hypotension is suspected, remotely measuring supine to standing BP using RPM and videoconferencing isn't recommended due to the risk of falls and potential inaccuracies in technique affecting results. In assessing supine to standing BP, the RPM clinician should facilitate an in-person assessment through the service or by coordinating with other relevant community healthcare services.

  • More about measuring a lying and standing blood pressure (Clinical Excellence Commission).

Pulse rate
  • RPM clinicians should consult a medical officer or designated clinician to assess the suitability of collecting pulse rate as part of the heart failure care pathway.
  • Atrial fibrillation (AF) is common in heart failure patients, ranging from 5% in NYHA Class I to 50% in NYHA Class IV. It is strongly associated with an increased stroke risk and can reduce cardiac output by up to 30%. Many automated BP monitors that also measure pulse rate cannot detect common arrhythmias, such as atrial or ventricular premature beats or atrial fibrillation, potentially causing reading errors. Consider undiagnosed arrhythmias when troubleshooting frequent self-measurement errors.
  • If patient is newly diagnosed with AF during an episode of RPM, they should be reassessed to determine baseline vital signs. Consider altered calling criteria (ACC).
  • For pulse rate monitoring in patients with a diagnosed arrhythmia, be aware of pulse rate error alerts and provide patient with strategies to manage any associated anxiety.
Pulse oximetry (SpO2)
  • Consider carefully in people with poor peripheral perfusion, which can impact the accuracy of finger oximeters measuring SpO2. This can trigger unnecessary alerts and escalation pathways.
  • If SpO2 is scheduled and the patient has poor peripheral perfusion, provide additional support on optimal finger probe usage. Use of the finger probe on the ear is not recommended for RPM patients at home.
Weight
  • Baseline ‘dry weight’ (the patient’s usual weight without excess fluid) must be manually entered into the RPM platform for each patient to facilitate tracking fluctuations.
  • To monitor against dry weight, advise patients to follow the four Ws: Wake, Wee, Weigh and Write. This means to weigh themselves immediately upon waking, after urination and before consuming food or drink, while wearing similar clothing each time. Patients should manually record this measurement in the monitoring system if it doesn't automatically upload results.
  • Weight fluctuations (gain or loss) exceeding 2kg within a 48-hour period require clinical assessment.
  • Assess RPM platforms according to their ability to trigger an alert for specific weight changes within a predetermined timeframe. If functionality is not available, clinicians should incorporate a workflow that involves altered calling criteria to trigger alerts for weight gain/loss from an agreed baseline or reviewing readings to detect any emerging trends.
  • SGLT2i has a diuretic effect and may increase the effect of loop diuretics. Consider the need to monitor for potential volume depletion.

Heart failure symptoms generally occur on exertion; however, they can also occur at rest, especially when lying down.

RPM clinicians should collaborate with the patient and their family member or carer to make an action plan. This encourages them to contact their GP or RPM service promptly upon experiencing specific symptoms relating to their heart failure.

For patient guidance on heart failure symptoms to monitor and when to seek a review from their care team or GP, see Living well with heart failure (Heart Foundation).

Health coaching and care coordination

The following considerations will assist RPM clinicians working with patients with heart failure.

Identification and management of symptoms

Help patients to recognise worsening signs and symptoms of heart failure and seek prompt assistance. This ensures they receive the necessary care and can effectively manage their condition.

Useful resources:

Recent hospitalisationSee Five Steps to a Safe Heart Failure Discharge (Heart Foundation).
Fluid management

Assess patient’s fluid management by checking for completion and trends in daily weight measurements, and asking about symptoms, such as:

  • oedema
  • worsening shortness of breath
  • abdominal distension
  • orthopnoea (breathing difficulties when lying flat)
  • paroxysmal nocturnal dyspnoea (shortness of breath during sleep that comes on suddenly, causing the person to wake up gasping).

Consult a specialist clinician or GP to determine if a flexible diuretic plan is suitable for the patient to support weight self-management.

Nutrition Encourage the patient to make small, lasting changes and develop heart-healthy eating habits that can be maintained after RPM discharge. See Nutrition resources for patients (Heart Foundation).
Heart failure programs

Support patient referral to a heart failure group or program if they agree and meet the eligibility criteria. These programs aim to boost function, enhance exercise endurance, offer oxygen conservation guidance, tackle risk factors and create supportive networks for patients.

Supporting services

For patients at high risk of hospitalisation or with complex health and social care needs, consider referral to a local integrated care program supportive care service (support with transition to end of life services),
local chronic disease management program or a service using the 3Ci model of care.

Resources

Heart failure resources for patients
Comprehensive education and management resources for heart failure patients.
Source: Heart Foundation Australia

Pilbara Aboriginal heart health program
Culturally relevant health information for Aboriginal and Torres Strait Islander people, produced by the Heart Foundation working with communities in Western Australia.
Source: Heart Foundation Australia

Heart education assessment rehabilitation toolkit
Patient resources on cardiac rehabilitation and heart failure management.
Source: Heart Online

How can I take an active role in managing my heart failure?
Patient resources on heart failure from NPS MedicineWise in conjunction with the National Heart Foundation of Australia.
Source: NPS MedicineWise

Your quick guide for patient heart failure wellbeing
Order this user-friendly fridge magnet.
Source: NSW Agency for Clinical Innovation

Resources for clinicians
Education and management resources to assist clinicians working with heart failure patients.
Source: Heart Foundation Australia

Cardiac Network resources
Resources including the 3Ci Model of Care; Guidelines for the prevention, detection and management of chronic heart failure in Australia; and NSW clinical service framework for chronic heart failure.
Source: Agency for Clinical Innovation

Heart education assessment rehabilitation toolkit
Resources for clinicians on cardiac rehabilitation and heart failure management.
Source: Heart Online

National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand’s Guidelines for the prevention, detection, and management of heart failure in Australia
Evidence-based guidance on the clinical management of patients with heart failure.
Source: Heart, Lung and Circulation

Australian Centre for Heart Health training
In-person and online training for clinicians working in cardiac rehabilitation.
Source: Australian Centre for Heart Health

APNA online learning
Flexible online courses for nurses working in primary healthcare.
Source: Australian Primary Care Nurses Association

References

  1. NHFA CSANZ Heart Failure Guidelines Working Group, et al. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018. Heart Lung Circ. 2018 Oct;27(10):1123-1208. DOI: 10.1016/j.hlc.2018.06.1042
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