- Adults (aged ≥18 years).
- Patients who have a confirmed diagnosis of systolic heart failure (HF) on echocardiography (ie, left ventricular ejection fraction <45% within the past 5 years).
- Patients who have experienced no deterioration of HF symptoms in the past 2 weeks resulting in hospitalisation or alteration of HF medication
You will find the full list of exclusion criteria is listed under Table 1 in our protocol paper: https://bmjopen.bmj.com/content/5/12/e009994
So our evidence is based on these criteria. We also have feasibility data on patients with HFpEF (EF >45%) but in only 50 patients : https://bmjopen.bmj.com/content/8/4/e019649
Cascading of training
- One of my staff Cardiac specialist nurse was unable to attend this training due to leave. Are we able to cascade the training to them in order for them to facilitate with our exercise physio who is on the course today to facilitate with their patients?
- The REACH-HF developers do not recommend facilitation of the REACH-HF manual without training or cascading of the facilitator training within services.
As per conventional cardiac rehab (CR) programmes there is a need to ensure that REACH-HF is supported by a multidisciplinary CR programme. REACH-HF Facilitators should be part of a wider multidisciplinary team organising the clinical care and cardiac rehabilitation /self-care support for the patient. This may include referring on to specialist (eg. psychological counselling, or specialist exercise / physiotherapy advice) as part of the core team or through an agreed referral pathway.
Having a co-attendee, trainee or supervisor at home visits/on site is also acceptable as long as one person (the facilitator) has been trained in the delivery of the REACH-HF programme (although we don’t believe it is necessary to have two staff present).
Thank you for your enquiry and interest in REACH-HF.
REACH-HF is a comprehensive 12 week home-based, health professional facilitated cardiac rehabilitation programme for patients with Heart Failure.
It includes a patient manual, progress tracker, exercises (chair based and walking), carers’ manual and relaxation.
The REACH-HF Service Delivery Guide has more information. You may access it from the REACH-HF website: http://sites.exeter.ac.uk/reach-hf/reach-hf-service-delivery-guide/
Apart from the main RCT trial, we have also delivered a pilot roll out of REACH-HF at four NHS cardiac rehab centres (Beacon sites – Gloucestershire, Belfast, Wirral, and University College Hospital, London) in 2019-20. Funding from Heart Research UK is enabling us to evaluate the delivery of REACH HF across four health boards in Scotland in 2021. In response to COVID-19, we provided a 2-day online training to nearly 90 health care professionals (cardiac rehab nurses, HF specialist nurses, exercise physiologists and others) from across the UK in 2020. Some of these have started delivering REACH HF and hope to continue through the pandemic and beyond. The online training courses are continuing and available through the Heart Manual Department or telephone on 0131 537 9127/9137 for dates in 2021.
The costs of REACH HF facilitator training by the Heart Manual Department are: £200 per participant attending the 2 day remotely delivered course plus a minimum purchase of 10 REACH HF intervention packs/ HF Manuals each @£30 per pack/HF Manual=£300, (including delivery) therefore a total cost of £500 per participant.
The Wirral Community Cardiovascular Rehabilitation Beacon site staff are happy to speak to interested cardiac rehab teams on their experience of the ‘real-life’ rollout of the programme. For more details please see: https://www.nice.org.uk/sharedlearning/delivering-rehabilitation-enablement-in-chronic-heart-failure-reach-hf-in-wirral
Please do contact us () if you have any further queries or if you are interested in adopting REACH-HF in your area.
Further information on REACH HF is also available from the NICE shared learning website: https://www.nice.org.uk/sharedlearning/covid-19-ready-rehabilitation-for-heart-failure-reach-hf-can-deliver
Thanks and best wishes,
In no particular order, the following are the key/recurring questions asked during the initial enquiry by clinicians during April-November 2021. All enquiries came from practicing regulated clinicians- specialist, Lead, one of the team, or overall service manager/clinician.
- Cost of training per person-the duration and delivery.
- Cost of HFMs now & in longer term & what the resources consisted of?
- How do they receive resources, re-order and store of them as required?
- How do they pay, process such and can we advise on that? E.g: Some had charity funds and could they pay by cheque? Their procurement will want to connect with one of our team.
- How would the REACH HFM work in ‘their’ practice, and the ability to think out loud on how they could make it happen within current parameters staff wise- i.e. try and minimise an (other) operational overhaul.
- How will REACH-HF ‘work’ within current clinical pathway e.g. explaining how they worked/what they offered currently/pre pandemic. How could they ‘modernise’ their service and gather info they could feed back to clinical managers.
- If they were regular Heart Manual users then they did ask: was it similar or how is it different?
- What is the frequency of updating in line with,’ x, y and z guidelines’. This was usually on the back of discussing other platforms/ resources sampled that they and their patients were disappointed with, plus the issues communicated that had not been acted on nor acknowledged.
The warm up for the chair based exercise is 5 minutes long and grants the required cardiac response pre-exercise. I wondered how this was achieved due to BACPR standards for the warm-up being 15 minutes to achieve the required cardiac response.
Most studies show that 5 to ten minutes is sufficient to achieve a warm up before commencing moderate levels of exertion. The higher the intensity the more warm up is required with 15 mins seen as optimal to help prepare healthy people and fitter patients to exercise at higher intensities.
In heart failure the situation is slightly different especially for those with lower levels of fitness and multiple comorbidities.
One of the challenges in managing exercise training in heart failure is to do enough exercise to help maintain fitness (which we know drops rapidly over time in this group) and to do so without exhausting patients. As a context the mean age of REACH-HF patients is over 70 years with an average of three additional comorbidities which means we are primarily setting exercise goals around maintenance of fitness.
With that context in mind most guidelines suggest shorter duration warm up for instance the ACPICR and EPG state in their guidance that it should be reduced in proportion to the main conditioning phase duration and expected intensity (see below). https://www.acpicr.com/publications/healthcare-professionals/
In respect of REACH-HF and chair based exercise (CBE) we have a built in warm-up before the main part. On top of that the main part of the CBE is also incremental in that minute-by-minute each set of exercise requires slightly more range of movement, co-ordination and repetitions with an aim to achieve an optimal level of exercise stimulus towards the end of the main period of the exercise training during each session. In summary the main part of our CBE programme incorporates increments of demand which continue to prepare the individual for the next level of exercise during each session.
The added value of the REACH-HF approach to warm-up is that our clinical trial showed no adverse events related to exercise and feedback from patients was strongly positive.
On the exercise component I noticed our Met values varied to ones printed in the document? I have attached our Incremental Shuttle Walk test to compare. I’m only querying this as I had a discussion with someone on the course about this and we were using different Met levels.
METs is murky water and estimates of METs even more so!
Measured METs per task will vary based on the point of reference during the task being measured.
For instance you would normally want to record the MET cost of an activity based on at least three minutes of activity at a particular level (often referred to as steady state).
Once you have the three minutes of data there's a dilemma: do you take the 1st, 2nd or 3rd minute value as your MET cost?
Or do you take the middle value or end value or the average of the three minutes?
You could - and many do - just take the peak MET value even if it's for less than one minute irrespective of where it occurs in the data timeline. All of these approaches lead to different MET values for the same task. This type of variation also leads to confusion in the literature.
There's possibly no right or wrong way but what is important is that people who produce MET tables state if their numbers are based on average or peak values. In REACH-HF we use average MET values related to the ISWT levels. If studies use peak values they will always produce higher METs per level than average MET values.
The other dilemma we have when using METS is the assumption that 1 MET = 3.5 ml 02/kg/min). This was calculated based on a 70kg person which doesn't resonate with many of our patients. To counter the impact of an 'estimate within an estimate the more scientifically orientated researchers (JB being one of them) directly measure resting metabolic rates (resting METs) for the actual individual. They are then able to divide the peak or average METs for a task by the individual's actual resting METs. It's good science but can't be done on mass in patient populations.
When you look at the array of MET values in the numerous tables that exist it's often the above permutations/approaches that can explain the differences.
In summary: ISWT MET values based on direct measurement (as outlined above) can lead to different values (mean vs peak). Estimated METs derived from average walking speed MET equations are at best a good guess but not even close to being accurate.
Thankfully, we have our clinical skills and judgement to work around these uncertainties.