Focused cardiac rehab programs grow rapidly
Debilitated surgical patients are primary market
When Sunnyview Rehabilitation Hospital in Schenectady, NY, opened its inpatient cardiac rehabilitation program in 1990, the six-bed unit treated just 170 patients the first year.Now, due to an increase in patients needing inpatient cardiac rehab, Sunnyview has expanded to 25 beds and treated 505 patients in 1996, says Rosann DeMeo-Peavey, RN, MS, cardiac rehabilitation program director.
Other rehabilitation hospitals with inpatient cardiac programs report similar increases in demand.
They attribute the expanded caseloads to tremendous advances in cardiac surgery, which allow sicker and older patients to undergo surgery for their conditions.
Although most patients have a brief convalescence, others, particularly the elderly and those who have postoperative complications, can benefit from an inpatient rehab program, DeMeo-Peavey says. Among the complications are stroke, congestive heart failure, infection, and arrhythmia, she says.
"The patients we see would have had a much more extensive hospital stay and may well have gone from there to long-term care. Because they may not have had the opportunity for aggressive rehabilitation in the long-term care setting, many may not have ever been able to go home," says Paul LaRaia, MD, chief of inpatient cardiology at Spaulding Rehabilitation Hospital in Boston.
When Spaulding started its inpatient cardiac rehabilitation program 15 years ago, it was the only rehab program in the country run by a cardiologist and staffed with trained cardiac nurses.
A mini-cardiac unit
Patients in the program are admitted to a mini-cardiac care unit with sophisticated monitoring equipment mixed with an aggressive rehabilitation program.The inpatient program was set up in conjunction with the postoperative open-heart surgery program at Massachusetts General Hospital, also in Boston.
Spaulding’s program combines the advantage of the acute care setting with the rehab setting. The program is staffed by a cardiologist, a cardiac nurse, and a large staff of rehabilitation professionals including physiatrists, physical therapists, and occupational therapists.
Instead of keeping them at Massachusetts General, the patients are transferred to Spaulding where they continue cardiac care and are closely monitored while they receive rehabilitation services.
The Spaulding program is individually tailored to each patient. The cardiologist writes a specific program based on general protocols of energy expenditure.
"These patients are very sick with multisystem diseases. They may have renal disease, pulmonary diseases, or vascular diseases. They tend to be an older population with an average age of 71. We have to treat these patients a little differently," LaRaia says.
Initially, the Spaulding patients cannot tolerate three hours of daily physical therapy. They start with simple bedside exercises, sometimes broken up into 10-minute sessions with an hour of rest in between.
The Spaulding staff has studied the effectiveness of using small-muscle-group isotonic exercises with debilitated cardiac patients. The patients may begin by doing low-weight resistive exercise in a single limb or muscle group, such as flexing one arm at a time.
Such exercises have a limited effect on the cardiovascular system, which means that the patients do not get fatigued, but they do develop strength in the various muscle groups. As the patients get stronger, therapists can use more traditional exercises to help the patients with their activities of daily living, LaRaia says.
Cost-effective outcomes
Between 90% and 95% of the patients at Spaulding go home with substantial improvements in their functional capacity. The cost is less than if they had stayed in the acute care facility."We feel the program is cost-effective and outcomes positive," LaRaia says.
At Moss Rehabilitation Hospital in Philadelphia, for example, a patient would be eligible for inpatient cardiac rehab if he or she has had a coronary artery bypass, had complications, and has not improved in acute care, says Harry Schwartz, MD, director of the hospital’s cardiopulmonary unit.
Cardiopulmonary patients at Moss generally have a 10- to 14-day length of stay. The interdisciplinary cardiopulmonary protocol includes nutrition, an aerobic conditioning training program, and energy conservation techniques.
"From a medical standpoint, we watch them like hawks. We are seeing them earlier and earlier after surgery, and they require more medical intervention than they used to," Schwartz says.
The therapy staff works with cardiac surgeons, cardiologists, or other consultants to make sure patients’ medications for postoperative arrhythmias are managed correctly and to wean patients off them when possible.
At Columbia Ocala Regional Medical Center in Ocala, FL, the therapy staff works with all patients before open-heart surgery to teach them what they will need to know when they go home, says Christine Wilson, RN, clinical coordinator for the cardiac rehabilitation program.
Therapists work with the patients after surgery, giving them instructions for walking and mild exercises to do while they recuperate at home. Because many patients are discharged three days after surgery, it is imperative that the therapy staff meet with them soon after surgery, Wilson says.
"We walk them up and down the halls. The patients have to be walking pretty well to be able to manage at home just three days after surgery," she says.
The in-hospital program emphasizes patient education. "Our biggest focus is to be an advocate for patients and their families. Sometimes, they just need someone to sit down and answer their questions," Wilson says.
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