Implementation strategy: one-stop recovery for cardiac surgical patients

"Fast-track" or "rapid recovery" for cardiac surgical patients is enjoying widespread use due to its benefits of increased patient comfort, enhanced quality of care, and cost-savings. Successful implementation of a fast-track program, however, may be challenged by physicians, the institution, or patients and their families. One-Stop Recovery is a fast-track program that emphasizes the benefits of traditional rapid recovery programs while addressing potential challenges.

Use of telephone follow-up for post-cardiac surgery patients

Telephone follow-up has been used in a variety of settings as a means of supporting patients post-discharge. This paper describes the implementation of a telephone follow-up service for cardiac surgical patients, both to monitor their progress and to bridge the gap between home and hospital. Surgical unit nurses called 1594 patients between May 1995 and October 1997. These calls were made a month after each patient had been discharged and a specially designed form was used as a guideline for the calls. This covered three main aspects of their recovery: discharge monitoring; medical problems; and convalescence problems. As well as providing a framework for the calls, the forms were then used for data collection. The forms were audited on a monthly basis with the results being communicated to the ward staff. Data gathered from the calls have highlighted areas where patient education needs to be improved, e.g. pain control, and this has been addressed. In October 1996, an evaluation of the service was performed. One hundred patients were sent a postal questionnaire asking for their views on the telephone service. Eighty-two of these were returned and the results of this survey are also contained in this report. Over time, the number of patients called each month has increased; information regarding support post-discharge has improved and the form used for calls has been revised to make the questions more appropriate.

Creating cost-efficient initiatives in social work practice in the cardiac program of an acute care hospital

All three cost-saving initiatives--the creation of a one-page application form to streamline the rehabilitation application process, the use of the resource specialist to assist with applications, and the development of an information package on cardiac rehabilitation--reflect a process whereby a creative idea, generating planning, activities, and follow-up resulted in a measurable effective change in practice. This process truly translated strategy into action (Kaplan, 1996) and is vital to the current rethinking in health care of how best to do our work (Coan, 1994). Because of this process, social workers in the cardiovascular surgical division of the cardiac program are better equipped to respond to the psychosocial needs of a growing cardiac population in a fiscally restrained environment.

An interdisciplinary approach to the rehabilitation of open-heart surgical patients

Quite often nurses in environments other than the immediate postoperative setting are responsible for the well-being of patients who have had open-heart surgery (OHS). These patients may be admitted to rehabilitation or home healthcare settings as early as 1 week after surgery. They may be deconditioned because of postoperative complications such as a cerebrovascular accident or cardiopulmonary compromise. Rehabilitation nurses in inpatient or home health environments are key members of the interdisciplinary team in terms of establishing standards of care for OHS patients after surgery. Coordinating care within an interdisciplinary team reduces fragmentation of care, improves patient outcomes, and enhances patient, family, staff, and physician satisfaction. This article focuses on empowering rehabilitation nurses as leaders and members of interdisciplinary teams as they establish standards for coordinating the postoperative care of OHS patients.

[Supervised cardiac rehabilitation for the patients with the disturbance of the motor function after cardiac surgery: the significance of physical therapists' participation]

There are sporadic instances of patients with the motor function disturbance of non-cardiac origin after cardiac surgery, and these patients may need prolonged post-operative cardiac rehabilitation. We established our cardiac rehabilitation program for post-operative patients and a total of 124 patients underwent the post-operative cardiac rehabilitation program (male 73, female 51, average age 60). Among them, 12 patients (9.7%) received the physical therapy for the disturbance of motor function post-operatively. These 12 patients were retrospectively studied. Physical therapies performed were the exercise therapy to improve the range of motion to prevent contracture in 3 patients with peroneal nerve palsy and drop foot, the exercise therapy for pre-operative or post-operative hemiplegia in 6 patients, the instruction of exercise for lumbago in 1 patient with spinal cord disease, respiratory physical therapy in 1 patient, and myotherapy for arthritis in 1 patient. Treatment with physical therapy was very useful in rehabilitating these patients. Active participation of physical therapists in cardiac rehabilitation for patients with the disturbance of motor function after cardiac surgery is possible. It is expected that their participation may improve the quality of life in this subset of patients.

Cardiac surgery and women

Coronary heart disease is just as serious a problem for women as it is for men, yet historically women have been significantly underrepresented in research studies related to the disease and treatment options, including cardiac surgery. Cardiac surgery is a proven therapy for the management of coronary heart disease in women. Research addressing the physical, psychosocial, and emotional issues women face during the preoperative, postoperative, and recovery phases of surgery is limited. Nurses play a pivotal role in the education and management of women undergoing cardiac surgery and need to be aware of unique issues related to the experience. This article reviews the literature pertaining to women's issues during the perioperative and recovery phases of cardiac surgery.

Complementary therapy and cardiac surgery

Mind-body techniques and complementary care may assist people who are undergoing surgery and those recovering from cardiac surgery to cope with the event, the process of recovery, and accompanying lifestyle changes. These approaches can provide cardiac patients with nonpharmacologic tools that may prevent further coronary artery disease and the development of dysrhythmias. The Complementary Care Center at Columbia-Presbyterian Medical Center was developed to clinically apply and research the use of nonallopathic, complementary modalities with patients receiving care at the medical center, including those undergoing cardiac surgery.

What is minimally invasive cardiac surgery?

Most patient concerns and demands for less invasive surgery are focused on comfort, cosmesis, and rehabilitation that are all related to the degree of invasiveness. The degree of invasiveness of cardiac surgery depends on two factors: the surgical approach--the length of the skin incision, the degree of retraction and aggression to the tissue, and the loss of blood--and the use of cardiopulmonary bypass. Regarding the surgical strategy, four categories of less invasive cardiac surgery can be distinguished: (1) direct coronary artery surgery via sternotomy on the beating heart (without extracorporeal circulation); (2) limited or modified approaches using conventional techniques and instruments with either conventional cardiopulmonary bypass or the EndoCPB endovascular cardiopulmonary bypass system; (3) minimally invasive direct coronary artery bypass on the beating heart via a parasternal or left anterior small thoracotomy; and (4) true Port-Access surgery in which all surgical acts are performed through ports and the heart is arrested with the Endoaortic Clamp catheter. These categories offer different advantages in terms of reducing invasiveness and may have different learning curves. Minimally invasive cardiac surgery is undergoing an explosive evolution, and although the indications and best strategies for the different categories are yet to be determined, the trend cannot be stopped. We try to distinguish between "fashionable" strategies and those that are truly revolutionary and investments in the future.

[Sanatorium rehabilitation of cardiosurgical patients]

The authors formulate a new approach to classification and therapy of clinical and mental complications after operations on the heart. Their clinical experience with 29% patients surgically treated for cardiac diseases (aortocoronary bypass and other operations) provided proofs of a good therapeutic effect of postoperative psychological correction performed in sanatorium (in the Central Army Sanatorium, in particular).

Psychological effects of cardiac surgery: a review of the literature

Cardiac surgery is now offered to more patients than ever before. Different age groups are affected by different forms of the disease and, as a result, patients range from new born infants to those in their eighties. In recent years attention has begun to focus on the psychological effects of such surgery. This article considers current research into the cognitive, psychiatric and psychological changes associated with cardiac surgery, with specific reference to coronary artery bypass grafting (CABG).

Patients' perceptions of their education needs in the first six weeks following discharge after cardiac surgery

The aim of this study was to discover what information and support patients feel they need in the 6-week rehabilitation period following discharge after cardiac surgery. It was undertaken at the request of the hospital multidisciplinary cardiac rehabilitation team to enable them to plan a package of information to meet those needs. It was a local study aiming to gain insight into the patients' own views by asking them to keep a diary over the 6-week period and then take part in an unstructured interview when they returned for their 6-week out-patient appointment. The analysis of the respondents' comments gave an insight into their whole experience of the first 6 weeks following discharge. The themes which emerged were wide-ranging and were grouped under the headings of the early discharge needs of pain relief and sleep promotion, psychological needs, practical needs and community support. To take the study forward, several recommendations were made to improve the rehabilitation experience. These included additions to the literature and patient education sessions, and changes to ensure a smoother transition into the community. The findings also suggest the need for improvements in and further research into the whole area of the psychological preparation for discharge after cardiac surgery.

Health patterns of cardiac surgery clients using home health care nursing services

The purpose of this study was to examine the health patterns of cardiac surgical patients in the home health care population and their relationships to outcomes and duration of home health care using Gordon's Functional Health Pattern framework. Home health care records of 96 cardiac surgical clients were reviewed. Admission health pattern data, reasons for admission, duration and outcomes of home care services, characteristics of hospital experience, and demographic data were analyzed. Dysfunctional health patterns were primarily in the area of activity/exercise. The most common reasons for admission were monitoring of cardiopulmonary status, wound care, and instruction on diet, medications, and cardiac regimen. The mean duration of home care was 28.8 days. Thirty percent of the sample were readmitted to the hospital. Duration of home care was shorter for those who were married and for those who reported weakness, tiredness, or fatigue as a chief complaint. Readmission to the hospital was more likely for those who had complications during their initial hospital stay and those who required at least partial assistance with bathing, dressing, feeding, or toileting. Implications for practice and research are discussed.

Functional outcomes of patients on a rehabilitation unit after open heart surgery

BACKGROUND

Compared with predecessors, the modern-day patient who undergoes cardiac surgery is sicker, is older, has more diffuse disease, has poorer ventricular function, and is more likely to be a repeat surgery. Patients hospitalized after open heart surgery in the 1990s, therefore, may require increasingly comprehensive rehabilitation services before returning to the community; however, information documenting functional progress during, and outcome after, a hospital-based rehabilitation program is scarce.

METHODS

During a 14-month period, a consecutive sample of 44 patients who underwent cardiac surgery and were admitted to a rehabilitation unit in a tertiary acute hospital was studied. Thirty-one patients had coronary artery bypass graft, six had valvular surgery, and seven had both. Each patient's functional status on admission and discharge from the rehabilitation unit was assessed using the Functional Independence Measure. Other data studied included patient age and sex, premorbid medical problems, type of cardiac surgery, length of stay, and occurrence of medical complications in the acute and rehabilitation units.

RESULTS

The mean Functional Independence Measure scores at rehabilitation unit admission and discharge were 76.1 +/- 17.1 and 96.7 +/- 19.4, respectively, and this difference was significant (P < 0.0001). The most significant correlates (alpha = 0.05) of the discharge Functional Independence Measure were admission Functional Independence Measure (P < 0.00001) and length of stay in the acute care unit (P = 0.0072). Age and presence of medical complications were not significant.

CONCLUSION

Patients who undergo open heart surgery, many of whom have medical comorbidity, are able to demonstrate substantial functional improvement on an inpatient rehabilitation program before hospital discharge.

Facilitating the recovery of open heart surgery patients through quality improvement efforts and CareMAP implementation

OBJECTIVE

To illustrate, using a literature review and CareMAPs, how care coordination and implementation of standard protocols can impact clinical outcomes for open heart surgery patients.

METHODS

A CareMAP for open heart surgery patients was developed by a multidisciplinary team. To evaluate the effectiveness of CareMAP implementation and specific quality improvement efforts, a pilot study was done that focused on increasing activity levels, decreasing ventilator time, and decreasing the frequency of arterial blood gas sampling for a sample of 55 open heart surgery patients. A rapid recovery program was developed based on the results of this pilot study. A multidisciplinary continuous quality improvement team was developed to focus on three primary areas: ventilator weaning time, activity regimens, and early transfer to the open heart surgery step-down unit. Forty-nine open heart surgery patients were included in the initial program evaluation.

RESULTS

The frequency of arterial blood gas sampling decreased from an average of 5.8 per patient to an average of 3.9 per patient. Postoperative length of stay also decreased by 1.3 days for diagnosis related group 106 patients, and 3.7 days for diagnosis related group 107 patients. Results of the pilot study demonstrated additional opportunities for improving the care of open heart surgery patients. Using the rapid recovery program, the average ventilator time decreased by 4.4 hours per patient. The average postoperative length of stay decreased to 4.7 days.

CONCLUSIONS

Through the quality improvement process and through the use of CareMAPs and specific protocols, the recovery of open heart surgery patients was facilitated.

Aerobic capacity of coronary heart disease (CHD) patients and its use in accommodating them in the workplace

According to the American Heart Association, more than 1.5 million new Americans suffer from heart attacks and angina each year. Approximately one million of these victims survive, making coronary heart disease (CHD) the most pressing health problem in America. Worldwide, survivors of CHD number in millions. The sufferers of CHD create a very significant economic burden on the society (hospital services, medications, diagnostic tests, physician fees, lost work days and productivity, providing disability income to the victims, etc.). Besides the economic burden, pain and suffering, actual and perceived loss of physical capabilities, and grief to the family are other significant losses the victims suffer. The restoration of CHD patients to an active and productive role in society, therefore, has become a major goal of rehabilitation experts. This work provides aerobic capacity data on 111 male and 32 female CHD patients (myocardial infarction, angioplasty, and coronary artery bypass). The Bruce treadmill protocol was used for measuring aerobic capacity. The post-phase II cardiac rehab aerobic capacity for males range from 0.83 l/min to 5.41 l/min. For females the corresponding range was from 0.67 l/min to 4.04 l/min. These capacity data can be used by designers to design jobs that can be performed by CHD patients who have undergone phase II cardiac rehabilitation; successful accommodation of CHD patients, besides restoring their psychological outlook, could result in the savings of billions of dollars. In addition, a listing of jobs that can be performed by CHD patients is provided. The literature-based metabolic energy requirements for these jobs are also provided.

Safety of medically supervised exercise in a cardiac rehabilitation center

Medically supervised exercise continues to have a low major cardiovascular complication rate. Direct gym supervision by a physician does not appear necessary for safety. The currently proposed cardiac rehabilitation risk stratification criteria do not appear to identify patients at risk for these major complications. The safety of exercise programs with less supervision and electrocardiographic telemetry monitoring is unknown.

Patients' perceptions of environmental factors that disturb sleep after cardiac surgery

BACKGROUND

Effective management of sleep disturbances after cardiac surgery requires insight into patients perceptions of which factors disturb sleep in the intensive care unit and after transfer from the intensive care unit.

OBJECTIVE

To describe patients perceptions of environmental factors that disturbed sleep after cardiac surgery.

SAMPLE

A convenience sample of 102 patients was surveyed in a 300-bed, acute-care teaching hospital.

METHOD

Patients were interviewed several days before discharge from the hospital and rated the extent to which specific factors disturbed their sleep while in the intensive care unit and after transfer.

RESULTS

The group mean for the extent of disturbance scores, averaged across all 35 environmental factors studied, was low during and after stay in the intensive care unit. However, selected items such as pain, and inability to get comfortable and perform a familiar nighttime routine, were moderately disturbing to many patients across phases of recovery. Patients varied widely in the number of factors, ranging from 0 to 33 factors, that disturbed sleep at least to some extent. Patients added factors that were not included in the original monitoring instrument.

CONCLUSIONS

Patients attribute disturbed sleep to specific factors after cardiac surgery. The number of factors that disturb sleep varies among patients. Nurses can modify many of the factors that disturb sleep to promote an environment that will facilitate improved sleep, thereby enhancing the acute phase of recovery from cardiac surgery.

Individual factors that influence sleep after cardiac surgery

BACKGROUND

Up to 50% of patients who undergo cardiac surgery report problems with sleep after cardiac surgery. Knowledge about which individual factors are associated with sleep problems after cardiac surgery would help nurses identify patients who are at greater risk for sleep problems during hospitalization.

OBJECTIVE

To compare patients perceptions of sleep before and during hospitalization for cardiac surgery and identify and analyze individual factors in relation to patients perceptions of sleep.

METHOD

A sample of 102 patients who underwent elective or emergent cardiac surgery were studied at a 300-bed teaching hospital in the northwestern United States. A few days before their anticipated discharge from the hospital, consenting patients completed questions about their sleep before hospitalization and the night before their interview.

RESULTS

Patients reported that they slept fewer hours in the hospital than at home. No differences were found in patients perceived depth and sufficiency of sleep, or refreshment before and after surgery. Patients who slept poorly at home did not report any worse sleep after surgery than patients who slept well at home. Women's perceptions about the sufficiency, refreshment, and quality of sleep were consistent before and after surgery, but no relationships were found among men's ratings. The length of sleep at home was positively related to the length of sleep after surgery in older patients.

CONCLUSIONS

Sleep length is related to patients perceptions of sleep after cardiac surgery. Gender and age are also related to qualitative aspects of sleep before and after surgery and can be instrumental in an individualized assessment of sleep patterns anticipated after cardiac surgery.

A rapid recovery program for cardiac surgery patients

Despite a strong national commitment to excellence in healthcare, the available resources are limited. Cardiac surgery consumes more healthcare resources than any other single treatment. It is imperative that healthcare professionals evaluate the traditional methods used to deliver quality care. Rapid recovery programs have been implemented in response to this challenge. The purpose of this article is to discuss development, implementation, and outcome evaluation of a rapid recovery program for cardiac surgery patients in a single health center. A multidisciplinary team examined care before, during, and after surgery, as well as after discharge. The team also evaluated standards of care and CARE Pathways. Changes in protocols were made to prevent the predictable complications of cardiac surgery. A decrease in intubation time, respiratory infections, wound infections, laboratory procedures, length of stay, and costs has been demonstrated. In a follow-up patient and family survey, high satisfaction with nursing care, patient and family education, and length of hospitalization has been voiced. Anticipated goals have been exceeded and improvements in standards continue to be made.

The effect of physical therapy on respiratory complications following cardiac valve surgery

STUDY OBJECTIVE

To determine whether higher personnel intensive chest physical therapy can prevent the atelectasis that routinely follows cardiac valve surgery.

DESIGN

Randomized, controlled trial.

SETTING

Tertiary care hospital.

PATIENTS

Seventy-eight patients undergoing elective cardiac valve surgery between October 1991 and April 1993 were enrolled.

INTERVENTIONS

Patients were randomized in an unmasked fashion to receive early mobilization and sustained maximal inflations (lower-intensity treatment) or to receive early mobilization, sustained maximal inflations, and single-handed percussions (higher-intensity treatment.)

MEASUREMENTS AND RESULTS

Clinical efficacy was determined by extent of atelectasis, length of ICU stay, total length of hospital stay, and personnel costs. The extent of postoperative atelectasis was similar in both groups on the fifth postoperative day. Postoperative values of FVC and FEV1 were reduced to a similar extent in both groups. Hospital stays and ICU stays were similar regardless of treatment. Physical therapy costs were highest in the higher-intensity therapy group.

CONCLUSIONS

Postoperative respiratory dysfunction is common but does not usually cause significant morbidity or prolong hospital stay. The routine prescription of high-intensity physical therapy does not improve patient outcomes but does add significantly to patient costs.

Mothers' information needs related to caring for infants at home following cardiac surgery

This study was conducted to examine the information needs of mothers whose infants had cardiac surgery. Thirty subjects ranked their perception of the importance and their level of understanding of 33 items in Mothers' Information Needs Instruments (MINI I and II) and completed the Comfort/Readiness Scale shortly before and after discharge. Both times, all mothers rated most items in the MINI as "extremely important" for them to know. Because many mothers' pre-discharge ratings of their understanding of crucial items was low and infant safety was jeopardized, the investigator ensured that additional teaching was received. Probably related to this unplanned intervention, mothers' understanding scores and their caregiving comfort levels were significantly higher post-discharge. The results support the use of standardized teaching and community follow-up for mothers charged with caring for infants who are recuperating from cardiac surgery at home.