The Impact of a Less Restrictive Poststernotomy Activity Protocol Compared With Standard Sternal Precautions in Patients Following Cardiac Surgery

On a healing journey together and apart: A Swedish critical incident technique study on family involvement from a patient perspective in relation to elective open-heart surgery

BACKGROUND

As family members affect patient outcomes following open-heart surgery, the objective was to provide updated knowledge on family involvement in to guide future interventions facilitating family involvement.

AIM

The aim was to explore and describe the experiences and actions of important situations of family involvement asexpressed by patients who underwent elective open-heart surgery in Sweden.

METHODOLOGICAL DESIGN AND JUSTIFICATION

The critical incident technique (CIT) was used, which is a qualitative research method suitable for clinical problems when a phenomenon is known but the experiences and consequences of it are not.

ETHICAL ISSUES AND APPROVAL

Considerations for patient integrity were made during the recruitment phase by ensuring that voluntary informed consent was obtained in two steps.

RESEARCH METHODS

Individual interviews were conducted with 35 patients who underwent open-heart surgery in Sweden in 2023. Important situations were analysed according to the CIT method.

RESULTS

Two main areas emerged: Patients described important situations of family involvement as experiences of mutual dependency while also being independent individuals. These experiences led to balancing healing and risk-taking activities as a family. The positive consequences of family involvement described by patients included improved recovery through practical help at home and emotional support.

CONCLUSIONS

As complements to preserving the existing positive aspects of family involvement, social support screening, the establishment of individualised visitation policies and the provision of professional and peer support earlier can improve patient recovery following open-heart surgery.

Post-sternotomy movement strategies in adults: a scoping review

AIMS

Post-sternotomy movement strategies for adults should be an evidence-informed approach and support a safe, independent return to daily activity. Recent new movement strategies have emerged. The aim of this scoping review was to identify and summarize the available evidence for post-sternotomy movement strategies in adults.

METHODS AND RESULTS

The electronic databases searched included MEDLINE, Embase, Sport Discus, CINAHL, Academic Search Complete, the Cochrane Library, Scopus, and PEDro. The search did not have a date limit. After 2405 duplicates were removed, 2978 records were screened, and 12 were included; an additional 2 studies were identified through reference searching for a total of 14 included studies. A data extraction table was used, and the findings are summarized in a tabular and narrative form. Three post-sternotomy movement strategies were identified in the literature: sternal precautions (SP), modified SP, and Keep Your Move in the Tube (KYMITT™). The authors suggested that the practice of SP was based on expert opinion and not founded in evidence. However, the evidence from the identified articles suggested that new movement strategies are safe and allow patients to choose an increased level of activity that promotes improved functional status and confidence.

CONCLUSION

More prospective cohort studies and multi-centred randomized control trials are needed; however, the current evidence suggests that modified SP and KYMITT™ are as safe as SP and can promote a patient-centred approach.

REGISTRATION

University of Calgary's Digital Repository PRISM http://hdl.handle.net/1880/115439.

Perioperative Care in Cardiac Surgery: A Joint Consensus Statement by the Enhanced Recovery After Surgery (ERAS) Cardiac Society, ERAS International Society, and The Society of Thoracic Surgeons (STS)

Enhanced Recovery After Surgery (ERAS) programs have been shown to lessen surgical insult, promote recovery, and improve postoperative clinical outcomes across a number of specialty operations. A core tenet of ERAS involves the provision of protocolized evidence-based perioperative interventions. Given both the growing enthusiasm for applying ERAS principles to cardiac surgery and the broad scope of relevant interventions, an international, multidisciplinary expert panel was assembled to derive a list of potential program elements, review the literature, and provide a statement regarding clinical practice for each topic area. This article summarizes those consensus statements and their accompanying evidence. These results provide the foundation for best practice for the management of the adult patient undergoing cardiac surgery.

arly u ervised ncremental esistance raining (ESpIRiT) following cardiac surgery via a median sternotomy: a study protocol of a multicentre randomised controlled trial

INTRODUCTION

There is no consistency in current practice pertaining to the prescription and progression of upper limb resistance exercise following cardiac surgery via median sternotomy. The aim of this study is to investigate whether less restrictive sternal precautions with the addition of early-supervised resistance training exercise improves upper limb function and facilitates recovery following median sternotomy.

METHODS AND ANALYSIS

This is double-blind randomised controlled trial, with parallel group, concealed allocation, blinding of patients and assessors, and intention-to-treat analysis. 240 adult participants who had median sternotomy from eight hospitals in Malaysia will be recruited. Sample size calculations were based on the unsupported upper limb test. All participants will be randomised to receive either standard or early supervised incremental resistance training. The primary outcomes are upper limb function and pain. The secondary outcomes will be functional capacity, multidomain recovery (physical and psychological), length of hospital stay, incidence of respiratory complications and quality of life. Descriptive statistics will be used to summarise data. Data will be analysed using the intention-to-treat principle. The primary hypothesis will be examined by evaluating the change from baseline to the 4-week postoperative time point in the intervention arm compared with the usual care arm. For all tests to be conducted, a p value of <0.05 (two tailed) will be considered statistically significant, and CIs will be reported. The trial is currently recruiting participants.

ETHICS AND DISSEMINATION

The study was approved by a central ethical committee as well as the local Research Ethics Boards of the participating sites (UKM:JEP-2019-654; Ministry of Health: NMMR-50763; National Heart Centre: IJNREC/501/2021). Approval to start was given prior to the recruitment of participants commencing at any sites. Process evaluation findings will be published in peer-reviewed journals and presented at relevant academic conferences.

TRIAL REGISTRATION NUMBER

International Standard Randomised Controlled Trials Number (ISRCTN17842822).

Effectiveness and Safety of Early Initiation of Poststernotomy Cardiac Rehabilitation Exercise Training: The SCAR Randomized Clinical Trial

Importance

Guidelines recommend that cardiac rehabilitation (CR) exercise training should not start until 6 weeks after sternotomy, although this is not evidence based. Limited data suggest that starting earlier is not detrimental, but clinical trials are needed.

Objective

To compare the effectiveness and safety of CR exercise training started either 2 weeks (early CR) or 6 weeks (usual-care CR) after sternotomy.

Design, Setting, and Participants

This was an assessor-blind, noninferiority, parallel-group, randomized clinical trial that conducted participant recruitment from June 12, 2017, to March 17, 2020. Participants were consecutive cardiac surgery sternotomy patients recruited from 2 outpatient National Health Service rehabilitation centers: University Hospital, Coventry, UK, and Hospital of St Cross, Rugby, UK.

Interventions

Participants were randomly assigned to 8 weeks of twice-weekly supervised CR exercise training starting either 2 weeks (early CR) or 6 weeks (usual-care CR) after sternotomy. Exercise training adhered to existing guidelines, including functional strength and cardiovascular components.

Main Outcomes and Measures

Outcomes were assessed at baseline (inpatient after surgery), after CR (10 or 14 weeks after sternotomy), and 12 months after randomization. The primary outcome was the change in 6-minute walk test distance from baseline to after CR. Secondary outcomes included safety, functional fitness, and quality of life.

Results

A total of 158 participants (mean [SD] age, 63 [11.5] years, 133 male patients [84.2%]) were randomly assigned to study groups; 118 patients (usual-care CR, 61 [51.7%]; early CR, 57 [48.3%]) were included in the primary analysis. Early CR was not inferior to usual-care CR (noninferiority margin, 35 m); the mean change in 6-minute walk distance from baseline to after CR was 28 m greater in the early CR group (95% CI, -11 to 66; P = .16). Mean differences for secondary outcomes were not statistically significant, indicating noninferiority of early CR. There were 46 vs 58 adverse events and 14 vs 18 serious adverse events in usual-care CR and early CR, respectively. There was no difference between the groups in the likelihood of participants having an adverse or serious adverse event.

Conclusions and Relevance

Starting exercise training from 2 weeks after sternotomy was as effective as starting 6 weeks after sternotomy for improving 6-minute walk distance. With appropriate precautions, clinicians and CR professionals can consider starting exercise training as early as 2 weeks after sternotomy.

Trial Registration

ClinicalTrials.gov Identifier: NCT03223558.

Preparation and support for physical activity following hospital discharge after coronary artery bypass graft surgery: A survey of current practice in New Zealand

BACKGROUND AND PURPOSE

Engagement in physical activity following coronary artery bypass graft (CABG) surgery has many benefits and also many potential barriers, especially during the first few months. It is important to explore current clinical practice before investigating ways to optimally prepare and support people to progressively increase their physical activity post-hospital discharge and to navigate the challenges. The aim of the study was to explore current practice in New Zealand hospital services for preparing and supporting people who have had CABG surgery to engage in physical activity following hospital discharge.

METHODS

Locality authorisation to participate in the study was sought from all 11 hospitals providing cardiac surgery services in New Zealand. The most senior health professional responsible for preparing people to engage in physical activity following CABG surgery was invited to participate by completing a purpose designed questionnaire on behalf of their hospital service. Respondents were also requested to provide any patient information handouts regarding progressive physical activity engagement following CABG surgery.

RESULTS

Responses were received from all nine hospitals that granted locality authorisation. All nine hospitals prepared people to engage in aerobic exercise prior to discharge, predominantly through the provision of a walking schedule. In contrast, no hospitals provided information about engagement in resistance exercise. There was wide variability in both the advice provided regarding sternal precautions and time to return to activities of daily living. Additionally, the facilitation of some elements of self-management for physical activity, in particular problem solving and providing follow up support outside of the cardiac rehabilitation setting was provided infrequently.

DISCUSSION

The findings demonstrated variability in service delivery in a number of areas and highlighted potential areas for improvement in light of what is known from the literature. Provision of follow up support for those unable to access outpatient cardiac rehabilitation is a key need.

Perceptions and experiences of engaging in physical activity following coronary artery bypass graft surgery

BACKGROUND

Engagement in physical activity (PA) during the recovery period following coronary artery bypass graft (CABG) surgery improves physical and health-related quality-of-life outcomes.

OBJECTIVE

To explore people's perceptions and experiences of engaging in PA during the first three months following CABG surgery.

METHODS

A mixed methods study design was utilized. Quantitative data were collected via accelerometer activity capture and standardized questionnaires. Qualitative data were collected via semi-structured interviews at weeks 1, 3, 6 and 12 post-hospital discharge. Interviews were analyzed using inductive thematic analysis.

RESULTS

Two overarching themes described the overall experience of engaging in PA: 1) "Navigating a difficult and unfamiliar road to recovery" and 2) "Still cautious but becoming more confident and able." These themes described the impact over time that various physical (i.e., fatigue, pain, medical complications, and physical deconditioning), psychological (i.e., fear, confidence, uncertainty, and motivation), and environmental (support) factors had on PA engagement, as well as the relationships between these factors.

CONCLUSION

The findings provided insight into the physical, psychological, and environmental factors that impacted participants' PA engagement following CABG surgery. This knowledge may benefit health professionals to optimize preparation and support for adults to engage in PA post-hospital discharge following CABG surgery.