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Acute heart failure

About

What is covered

This interactive flowchart covers diagnosing and managing acute heart failure.

Updates

Updates to this interactive flowchart

22 March 2016 Link added to the MHRA website on the latest published advice on the concomitant use of spironolactone and renin-angiotensin system drugs in heart failure concerning the risk of potentially fatal hyperkalaemia.
2 December 2015 Acute heart failure (NICE quality standard 103) added.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on diagnosing and managing acute heart failure in an interactive flowchart

What is covered

This interactive flowchart covers diagnosing and managing acute heart failure.

Updates

Updates to this interactive flowchart

22 March 2016 Link added to the MHRA website on the latest published advice on the concomitant use of spironolactone and renin-angiotensin system drugs in heart failure concerning the risk of potentially fatal hyperkalaemia.
2 December 2015 Acute heart failure (NICE quality standard 103) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Extracorporeal membrane oxygenation (ECMO) for acute heart failure in adults (2014) NICE interventional procedures guidance 482
Acute heart failure (2015) NICE quality standard 103
CentriMag for heart failure (2017) NICE medtech innovation briefing 92

Quality standards

Quality statements

Single measurement of natriuretic peptide

This quality statement is taken from the acute heart failure quality standard. The quality standard defines clinical best practice for the diagnosis and management of acute heart failure in adults and should be read in full.

Quality statement

Adults presenting to hospital with new suspected acute heart failure have a single measurement of natriuretic peptide.

Rationale

Natriuretic peptide testing (B-type natriuretic peptide [BNP] or N-terminal pro B type natriuretic peptide [NT proBNP]) is an important tool for rapidly assessing adults presenting to hospital with new suspected acute heart failure. It can be used to rule out a diagnosis of heart failure or to see if further investigation with echocardiography is needed. It can save time and distress for the adult presenting with new suspected acute heart failure.

Quality measures

Structure
Evidence of local arrangements to ensure that adults presenting to hospital with new suspected acute heart failure have a single measurement of natriuretic peptide.
Data source: Local data collection.
Process
a) Proportion of adults presenting to hospital with new suspected acute heart failure who have a single measurement of natriuretic peptide.
Numerator – the number in the denominator who have a single measurement of natriuretic peptide.
Denominator – the number of presentations of adults to hospital with new suspected acute heart failure.
Data source: Local data collection. National data are collected in the National Institute for Cardiovascular Outcomes Research heart failure audit 2012–2013.
b) Proportion of hospitals that use appropriate assay thresholds of plasma BNP less than 100 ng/litre and plasma NT-proBNP less than 300 ng/litre.
Numerator – the number in the denominator that use appropriate assay thresholds of plasma BNP less than 100 ng/litre and plasma NT-proBNP less than 300 ng/litre.
Denominator – the number of hospitals in England to which people may present with suspected acute heart failure.
Data source: Local data collection.
Outcome
a) Mortality rates.
Data source: Local data collection. National data are collected in the National Institute for Cardiovascular Outcomes Research heart failure audit 2012–2013.
b) Length of stay.
Data source: Local data collection. National data are collected in the National Institute for Cardiovascular Outcomes Research heart failure audit 2012–2013.
c) Readmission rates.
Data source: Local data collection. National data are collected in the National Institute for Cardiovascular Outcomes Research heart failure audit 2012–2013.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (cardiac service providers) ensure that adults presenting to hospital with new suspected acute heart failure have a single measurement of natriuretic peptide that is undertaken by the cardiac team to rule out a diagnosis of heart failure. Also, hospitals in England to which people may present with suspected acute heart failure ensure they use appropriate assay thresholds of plasma BNP less than 100 ng/litre and plasma NT-proBNP less than 300 ng/litre.
Healthcare professionals ensure that adults with new suspected acute heart failure have a single measurement of natriuretic peptide on presentation to hospital to rule out a diagnosis of heart failure.
Commissioners (clinical commissioning groups) ensure that adults with new suspected acute heart failure have a single measurement of natriuretic peptide on presentation to hospital to rule out a diagnosis of heart failure.

What the quality statement means for patients, service users and carers

Adults presenting at hospital with new suspected acute heart failure have their natriuretic peptide (also known as BNP or NT-proBNP) level in their blood measured. This test is a quick way for doctors to find out whether the person is likely to have heart failure or if they need further assessment to see if their symptoms are caused by something else.

Source guidance

  • Acute heart failure (2014) NICE guideline CG187, recommendation 1.2.2 (key priority for implementation)

Definitions of terms used in this quality statement

Natriuretic peptide
A protein substance secreted by the wall of the heart when it is stretched or under increased pressure. It has several forms and its level can be raised in a number of conditions, including heart failure. A normal natriuretic peptide level means that heart failure is unlikely, and its measurement can be used to exclude a diagnosis of heart failure.
[Adapted from acute heart failure (NICE guideline CG187) full guideline]
Appropriate assay thresholds of plasma BNP to assist in ruling out the diagnosis of heart failure
  • Plasma BNP less than 100 ng/litre
  • Plasma NT-proBNP less than 300 ng/litre.
[Adapted from acute heart failure (NICE guideline CG187) full guideline]

Transthoracic doppler 2D echocardiography

This quality statement is taken from the acute heart failure quality standard. The quality standard defines clinical best practice for the diagnosis and management of acute heart failure in adults and should be read in full.

Quality statement

Adults admitted to hospital with new suspected acute heart failure and raised natriuretic peptide levels have a transthoracic doppler 2D echocardiogram within 48 hours of admission.

Rationale

Performing a transthoracic doppler 2D echocardiogram within 48 hours of hospital admission for adults with new suspected acute heart failure and raised natriuretic peptide levels will enable earlier diagnosis and appropriate management in terms of pharmacological treatment, location of care and relevant input from the specialist heart failure team.

Quality measures

Structure
Evidence of local arrangements to ensure that adults admitted to hospital with new suspected acute heart failure and raised natriuretic peptide levels have a transthoracic doppler 2D echocardiogram within 48 hours of admission.
Data source: Local data collection.
Process
Proportion of adults admitted to hospital with new suspected acute heart failure and raised natriuretic peptide levels who have a transthoracic doppler 2D echocardiogram within 48 hours of admission.
Numerator – the number in the denominator who have a transthoracic doppler 2D echocardiogram within 48 hours of admission.
Denominator – the number of hospital episodes of adults with new suspected acute heart failure and raised natriuretic peptide levels.
Data source: Local data collection.
Outcome
a) Mortality rates.
Data source: Local data collection. National data are collected in the National Institute for Cardiovascular Outcomes Research heart failure audit 2012–2013.
b) Length of stay.
Data source: Local data collection. National data are collected in the National Institute for Cardiovascular Outcomes Research heart failure audit 2012–2013.
c) Incidence of adverse events (withdrawal of beta-blockers and other disease-modifying drugs).
Data source: Local data collection. National data are collected in the National Institute for Cardiovascular Outcomes Research heart failure audit 2012–2013.
d) Readmission rates.
Data source: Local data collection. National data are collected in the National Institute for Cardiovascular Outcomes Research heart failure audit 2012–2013.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (cardiac and radiology services) ensure that adults admitted to hospital with new suspected acute heart failure and raised natriuretic peptide levels have a transthoracic doppler 2D echocardiogram within 48 hours of admission.
Healthcare professionals ensure that adults admitted to hospital with new suspected acute heart failure and raised natriuretic peptide levels have a transthoracic doppler 2D echocardiogram within 48 hours of admission.
Commissioners (clinical commissioning groups) ensure that adults admitted to hospital with new suspected acute heart failure and raised natriuretic peptide levels have a transthoracic doppler 2D echocardiogram within 48 hours of admission.

What the quality statement means for patients, service users and carers

Adults admitted to hospital with new suspected acute heart failure have their natriuretic peptide levels (also known as BNP or NT-proBNP) in their blood measured. If the level is raised, they have an echocardiogram within 48 hours of admission to help find out if there is something wrong with their heart.

Source guidance

  • Acute heart failure (2014) NICE guideline CG187, recommendations 1.2.3 (key priority for implementation) and 1.2.4 (key priority for implementation)

Definition of terms used in this quality statement

Transthoracic doppler 2D echocardiogram
An echocardiogram is a test that uses ultrasound waves to measure the pumping action and structure of the heart, including the heart valves. A probe is moved over the surface of the chest and picks up echoes of sound (similar to an ultrasound scan used in pregnancy), which are shown as a picture on a screen.
[Adapted from Information for the public for acute heart failure: diagnosis and assessment]

Organisation of care – early specialist input

This quality statement is taken from the acute heart failure quality standard. The quality standard defines clinical best practice for the diagnosis and management of acute heart failure in adults and should be read in full.

Quality statement

Adults admitted to hospital with acute heart failure have input within 24 hours of admission from a dedicated specialist heart failure team.

Rationale

A dedicated specialist heart failure team with early involvement is important for cost-effective care. It can also positively contribute to rapid diagnosis, reduced readmissions and better quality of life. Ongoing input of the dedicated specialist heart failure team will also help to ensure appropriate care and make subsequent readmission less likely.

Quality measures

Structure
Evidence of local arrangements to ensure that adults admitted to hospital with acute heart failure have input within 24 hours of admission from a dedicated specialist heart failure team.
Data source: Local data collection.
Process
a) Proportion of adults admitted to hospital with acute heart failure who have input within 24 hours of admission from a dedicated specialist heart failure team.
Numerator – the number in the denominator who receive input within 24 hours of admission from a dedicated specialist heart failure team.
Denominator – the number of adults admitted to hospital with acute heart failure.
Data source: Local data collection. National data are collected in the National Institute for Cardiovascular Outcomes Research heart failure audit 2012–2013.
Outcome
a) Mortality rates.
Data source: Local data collection. National data are collected in the National Institute for Cardiovascular Outcomes Research heart failure audit 2012–2013.
b) Readmission rates.
Data source: Local data collection. National data are collected in the National Institute for Cardiovascular Outcomes Research heart failure audit 2012–2013.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (cardiac service providers) ensure that adults admitted to hospital with acute heart failure have input within 24 hours of admission from a dedicated specialist heart failure team.
Healthcare professionals ensure that adults admitted to hospital with acute heart failure have input within 24 hours of admission from a dedicated specialist heart failure team.
Commissioners (clinical commissioning groups) ensure that adults admitted to hospital with acute heart failure have input within 24 hours of admission from a dedicated specialist heart failure team.

What the quality statement means for patients, service users and carers

Adults admitted to hospital with acute heart failure have contact with a team within 24 hours of admission that specialises in treating heart failure and that is involved in their early care.

Source guidance

  • Acute heart failure (2014) NICE guideline CG187, recommendation 1.1.2 (key priority for implementation)

Definitions of terms used in this quality statement

Input within 24 hours of hospital admission
Review and address the needs of acute heart failure patients within 24 hours of hospital admission.
[Expert consensus]
Dedicated specialist heart failure team
This specialist inpatient team includes doctors, nurses (including heart failure specialist nurses), pharmacists, physiotherapists and psychologists, and has access to a palliative care specialist and other expertise as required. The team is led by a consultant specialist with a sub-speciality interest in heart failure. This team is based on a cardiology ward but also provides outreach services to heart failure patients on all other wards within the hospital. It is also part of a broader multidisciplinary specialist team working across primary and secondary care, as outlined by NICE guidance.
[Adapted from chronic heart failure (2010) NICE guideline CG108 and expert consensus]

Starting or continuing beta-blocker treatment

This quality statement is taken from the acute heart failure quality standard. The quality standard defines clinical best practice for the diagnosis and management of acute heart failure in adults and should be read in full.

Quality statement

Adults with acute heart failure due to left ventricular systolic dysfunction are started on, or continue with, beta-blocker treatment during their hospital admission.

Rationale

In-hospital introduction of beta-blockers is associated with increased use of beta-blockers at follow-up and better long-term outcomes such as fewer adverse events and reduced mortality. Also, it is important that beta-blocker treatment is continued for adults who are already taking it.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with acute heart failure due to left ventricular systolic dysfunction are started on, or continue with, beta-blocker treatment during their hospital admission.
Data source: Local data collection. National data are collected in the National Institute for Cardiovascular Outcomes Research heart failure audit 2012–2013.
Process
a) Proportion of adults with acute heart failure due to left ventricular systolic dysfunction who are started on beta-blocker treatment during their hospital admission.
Numerator – the number in the denominator who are started on beta blocker treatment during their hospital admission.
Denominator – the number of hospital admissions of adults with acute heart failure due to left ventricular systolic dysfunction in which the patient is not already taking a beta-blocker.
Data source: Local data collection.
b) Proportion of adults with acute heart failure due to left ventricular systolic dysfunction who continue with beta-blocker treatment during their hospital admission.
Numerator – the number in the denominator who continue beta blocker treatment during their hospital admission.
Denominator – the number of hospital admissions of adults with acute heart failure due to left ventricular systolic dysfunction.
Data source: Local data collection.
Outcome
a) Mortality rates.
Data source: Local data collection. National data are collected in the National Institute for Cardiovascular Outcomes Research heart failure audit 2012–2013.
b) Readmission rates.
Data source: Local data collection. National data are collected in the National Institute for Cardiovascular Outcomes Research heart failure audit 2012–2013.
c) Incidence of adverse events (withdrawal of beta-blockers and other disease-modifying drugs).
Data source: Local data collection. National data are collected in the National Institute for Cardiovascular Outcomes Research heart failure audit 2012–2013.
d) Beta-blocker use at follow-up.
Data source: Local data collection.
e) Readmission rates.
Data source: Local data collection. National data are collected in the National Institute for Cardiovascular Outcomes Research heart failure audit 2012–2013.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (cardiac service providers) ensure that adults with acute heart failure due to left ventricular systolic dysfunction are started on, or continue with, beta-blocker treatment during their hospital admission.
Healthcare professionals ensure that adults with acute heart failure due to left ventricular systolic dysfunction are started on, or continue with, beta-blocker treatment during their hospital admission.
Commissioners (clinical commissioning groups) ensure that adults with acute heart failure due to left ventricular systolic dysfunction are started on, or continue with, beta-blocker treatment during their hospital admission.

What the quality statement means for patients, service users and carers

Adults with acute heart failure due to left ventricular systolic dysfunction (known as LVSD, where the pumping chamber of the heart is not pumping well) start or continue beta-blockers while they are in hospital.

Source guidance

  • Acute heart failure (2014) NICE guideline CG187, recommendation 1.5.2 (key priority for implementation)

Definitions of terms used in this quality statement

Beta-blocker
Treatment for heart failure, heart rhythm disturbances, angina and heart attacks, and high blood pressure.
[Adapted from acute heart failure (NICE guideline CG187) full guideline]

Drug therapy

This quality statement is taken from the acute heart failure quality standard. The quality standard defines clinical best practice for the diagnosis and management of acute heart failure in adults and should be read in full.

Quality statement

Adults admitted to hospital with acute heart failure and reduced left ventricular ejection fraction are offered an angiotensin-converting enzyme (ACE) inhibitor and an aldosterone antagonist.

Rationale

Early initiation of ACE inhibitors and aldosterone antagonists for adults with acute heart failure is positively associated with improved outcomes such as lower mortality and readmission rates. If the ACE inhibitor has intolerable side effects, an angiotensin receptor blocker will be offered.

Quality measures

Structure
Evidence of local arrangements to ensure that adults admitted to hospital with acute heart failure and reduced left ventricular ejection fraction are offered an ACE inhibitor and an aldosterone antagonist.
Data source: Local data collection. National data are collected in the National Institute for Cardiovascular Outcomes Research heart failure audit 2012–2013.
Process
Proportion of new hospital admissions for adults with acute heart failure and reduced left ventricular ejection fraction when an ACE inhibitor and an aldosterone antagonist are offered.
Numerator – the number in the denominator treated with an ACE inhibitor and an aldosterone antagonist.
Denominator – the number of new hospital admissions for adults with acute heart failure and reduced left ventricular ejection fraction.
Data source: Local data collection.
Outcome
a) Mortality rates.
Data source: Local data collection. National data are collected in the National Institute for Cardiovascular Outcomes Research heart failure audit 2012–2013.
b) Readmission rates.
Data source: Local data collection. National data are collected in the National Institute for Cardiovascular Outcomes Research heart failure audit 2012–2013.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (cardiac service providers) ensure that adults admitted to hospital with acute heart failure and reduced left ventricular ejection fraction are offered an ACE inhibitor and an aldosterone antagonist.
Healthcare professionals ensure that adults admitted to hospital with acute heart failure and reduced left ventricular ejection fraction are offered an ACE inhibitor and an aldosterone antagonist.
Commissioners (clinical commissioning groups) ensure that adults admitted to hospital with acute heart failure and reduced left ventricular ejection fraction are offered an ACE inhibitor and an aldosterone antagonist.

What the quality statement means for patients, service users and carers

Adults admitted to hospital with acute heart failure and reduced left ventricular ejection fraction are offered an angiotensin-converting enzyme inhibitor (also known as an ACE inhibitor) and an aldosterone antagonist.

Source guidance

  • Acute heart failure (2014) NICE guideline CG187, recommendation 1.5.4 (key priority for implementation)

Definition of terms used in this quality statement

Reduced left ventricular ejection fraction
The fraction of blood that is pumped out from the left ventricle during each heartbeat. In healthy people it is typically at least 55%. It is reduced in systolic heart failure.
[Expert consensus]

Follow-up clinical assessment

This quality statement is taken from the acute heart failure quality standard. The quality standard defines clinical best practice for the diagnosis and management of acute heart failure in adults and should be read in full.

Quality statement

Adults with acute heart failure have a follow-up clinical assessment by a member of the community- or hospital-based specialist heart failure team within 2 weeks of hospital discharge.

Rationale

It is important that adults with acute heart failure have early specialist heart failure follow up by a member of the community- or hospital based specialist heart failure team within 2 weeks of hospital discharge to reduce early readmissions, achieve better long term outcomes and improve their quality of life.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with acute heart failure have a follow-up clinical assessment by a member of the community- or hospital-based specialist heart failure team within 2 weeks of hospital discharge.
Data source: Local data collection. National data are collected in the National Institute for Cardiovascular Outcomes Research heart failure audit 2012–2013.
Process
Proportion of adults with acute heart failure who have a follow-up clinical assessment by a member of the community- or hospital-based specialist heart failure team within 2 weeks of hospital discharge.
Numerator – the number in the denominator who have a follow-up clinical assessment by a member of the community- or hospital based specialist heart failure team within 2 weeks of hospital discharge.
Denominator – the number of hospital discharges of adults with a diagnosis of acute heart failure.
Data source: Local data collection.
Outcome
a) Mortality rates.
Data source: Local data collection. National data are collected in the National Institute for Cardiovascular Outcomes Research heart failure audit 2012–2013.
b) Readmission rates.
Data source: Local data collection. National data are collected in the National Institute for Cardiovascular Outcomes Research heart failure audit 2012–2013.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (cardiac service providers) ensure that adults with acute heart failure have a follow-up clinical assessment by a member of the community- or hospital based specialist heart failure team within 2 weeks of hospital discharge.
Healthcare professionals (community- or hospital-based specialist heart failure team) undertake a follow-up clinical assessment for adults with acute heart failure within 2 weeks of hospital discharge.
Commissioners (clinical commissioning groups) ensure that adults with acute heart failure have a follow-up clinical assessment by a member of the community- or hospital-based specialist heart failure team within 2 weeks of hospital discharge.

What the quality statement means for patients, service users and carers

Adults with acute heart failure have a follow-up assessment by a member of the community- or hospital based heart failure team within 2 weeks of hospital discharge.

Source guidance

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

NICE has produced resources to help implement its guidance on:

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Glossary

level 2 care is for people needing more detailed observation or intervention, including support for a single failing organ system or postoperative care and for those stepping down from higher levels of care. From levels of critical care for adult patients 2009 (Intensive Care Society)

Paths in this pathway

Pathway created: October 2014 Last updated: August 2017

© NICE 2017. All rights reserved. Subject to Notice of rights.

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