Cardiac Rehabilitation at AUBMC

Cardiac Rehabilitation at AUBMC Clinical Protocols and The Role of The Advanced Practice Nurse Presentation by: Mohamad Issa, MSN, BSN, BC- RN, AUBMC CCU

OUTLINE Background on cardiovascular diseases History of cardiac rehabilitation Cardiac rehabilitation models The proposed AUBMC cardiac rehabilitation program Cardiac rehabilitation evaluation

BACKGROUND ON CARDIOVASCULAR DISEASES

FACTS ABOUT CARDIOVASCULAR DISEASES Leading cause of death in the world. (Mathers et al, 2001; WHO 2002) Coronary artery disease (CAD) accounts for one third of global deaths. (LSCARDIO, 2012) In the US 915,000 Americans suffer from a myocardial infarction, more than 30% of them will have a second and potentially fatal event. (Mozaffarian et al, 2013) In Lebanon CAD accounts for 45% of all deaths (WHO, 2010) and for 60% of deaths in older adults. (LSCARDIO, 2012)

SIGNIFICANCE Coronary artery disease and heart failure are the two most common cardiac diseases, mandate changes in lifestyle, mainly diet, exercise, smoking cessation, in addition to taking prescribed medications in order to prevent recurrent exacerbations and to reduce cardiovascular risk. Cardiac rehabilitation programs provide the infra-structure that allows cardiac patients to change unhealthy behavior and improve their functional capacity.

DEFINITION OF CARDIAC REHABILITATION The Cardiac Rehabilitation Working Group of the European Society of Cardiology (ESC) has defined cardiac rehabilitation as: The sum of interventions required to ensure the best physical, psychological and social conditions so that patients with chronic or post-acute cardiac disease may, by their own efforts, preserve or assume their proper place in society (Goble a & Worcester, 1999)

WHY CARDIAC REHABILITATION? Reduces the risk of a future cardiac events by stabilizing, slowing, or even reversing the progression of cardiovascular diseases. Has shown significant improvement in clinical outcomes of patients with various cardiovascular diseases. (Balady, et al., 2011) Significantly reduces cardiovascular mortality, and hospital readmission. (Heran et al., 2011)

WHY CARDIAC REHABILITATION (CONT D) In heart failure patients Reduces the risk of all cause hospitalizations and hospitalizations due to heart failure. Improves quality of life with no evidence of harm or death associated with participation in rehabilitation. Lowers mortality on the long run. (Taylor et al., 2014)

PURPOSE OF THE PROJECT To develop the clinical protocols and documentation forms of the cardiac rehabilitation program at AUBMC, with an emphasis on the role of the advanced practice nurse (APN).

HISTORY OF CARDIAC REHABILITATION

HISTORY OF CARDIAC REHABILITATION 1772: Heberden published a case study about an exercise program for a patient with chest pain. 1799: Parry motioned that physical activity can enhance conditions of patients with chest pain. 1912: Henrich mentioned the need of rest for up to 2 months following Myocardial Infarction (MI) (Certo, 1985) 1930s: There was an increase in number of retired workers due to MI, so, the New York State Employment Service asked the New York Heart Association (NYHA) to investigate the safety level of activity after a cardiac event. (Certo, 1985)

HISTORY OF CARDIAC REHABILITATION (CONT D) 1960s: evidence on the beneficial effect of physical activity following cardiac events was established. End of 1960: first in-patient program of supervised activity was started. (Certo, 1985) 1970s: the first physical activity program for patients after hospital discharge was started by Hellerstein et al. (Certo, 1985) Since then: many cardiac rehabilitation models were developed in North America, Europe, and Australia.

CARDIAC REHABILITATION MODELS

CARDIAC REHABILITATION MODELS American Model American College of Cardiology/American Heart Association (ACC/AHA) 2010 British Association for Cardiovascular Prevention and Rehabilitation /National Institute for Health and Clinical Excellence (BACPR & NICE) 2013 British Model Australian model National Heart Foundation of Australia and the Australian Cardiac Rehabilitation Association (NHFA & ACRA) 2004

AMERICAN MODEL Cardiac rehabilitation staffs: Medical director, APN, and physical therapist (PT). (Balady et al., 2010) Divides the program into four phases: I. In-patient phase II. Early ambulatory out-patient phase III. Late ambulatory out-patient phase IV. Maintenance phase (Balady et al., 2010)

AMERICAN MODEL: CORE COMPONENTS Exercise training Baseline patient assessment Psychosocial treatment and support Nutritional Management Management of risk factors

BRITISH CARDIAC REHABILITATION MODEL Core components are similar to those of American model. British model divides CR into seven stages clinical pathway.

AUSTRALIAN MODEL OF CARDIAC REHABILITATION This model divides CR into three phases In-patient rehabilitation Out-patient rehabilitation program Ongoing preventive approach CR staffs shall include An expert center coordinator A health professional trained in cardiac rehabilitation who holds a degree in medicine, nursing, or physical therapy. Staff member who is specialist in providing education for adults. (NHFA & ACRA, 2004)

THE PROPOSED AUBMC CARDIAC REHABILITATION PROGRAM

SCIENTIFIC & PRACTICE BACKGROUND The proposed AUBMC model of cardiac rehabilitation is adapted from AHA, ACC, BACPR, and the NICE guidelines of cardiac rehabilitation. The model is also aligned with the latest guidelines for the management of hypertension, dyslipidemia, and diabetes; which have been released by the Joint National Committee (JNC 8) in 2014, Adult Treatment Panel (ATP IV) in 2013, and the American Diabetes Association (ADA) in 2014.

REHABILITATION CENTER STAFF Human resources shall include: CR medical director Oversees the multidisciplinary staff Make sure that referral and enrollment are being implemented correctly Oversees the progression of enrolled patients APN Physical therapist. Dietitians and psychologists will be invited by consultation.

REHABILITATION CENTER STAFF: ROLE OF APN Performs with the CR medical director the inhospital rehabilitation. Coordinates the out-hospital rehabilitation program. His/her role will be emphasized while discussing the journey of CR at AUBMC.

INCLUSION CRITERIA Patients who underwent revascularization either by Percutaneous Transluminal Coronary Angioplasty (PTCA) or Coronary Artery Bypass Grafting (CABG). Those with diagnosis of chronic stable angina, or stable heart failure. Following insertion of Automated Implantable Cardioverter-Defibrillator (AICD) or Cardiac Resynchronization Therapy Defibrillator (CRTD).

INCLUSION CRITERIA Following heart valve repair/replacement, heart transplantation and Left Ventricular Assist Device (LVAD) insertion. Other Atherosclerotic Cardiovascular Diseases like peripheral arterial disease (BACPR, 2012) Patients are enrolled through out-patient settings by their primary physician, or directly during their hospitalization after their cardiovascular disease.

JOURNEY OF CARDIAC REHABILITATION (CR) AT AUBMC The APN or CR medical director visits the candidates during their hospitalization due to a cardiovascular disease. During their visit, The APN or CR medical director introduces the service, provides patients with AHA fact sheet, explains about the program and answers questions, clarifies financial cost or coverage, and secures an informed consent for cardiac rehabilitation.

IN-PATIENT PHASE The APN or CR medical director Fills referral form, and performs initial assessment. Performs early ambulation, low intensity activities, and provides education about current cardiac diseases and modification of risk factors Fills in-patient rehabilitation form. One week after discharge, the APN calls the patient to remind him/her about their participation in the out-patient phase and the proposed date (Davies et al., 2010)

OUT-PATIENT PHASE Starts two weeks after discharge from the hospital. It consists of twelve weeks of rehabilitation, divided between 6 weeks of monitored sessions and 6 weeks of unmonitored sessions. There are three sessions per week. CR medical director, APN, and PT document on the out-patient CR form. The AUBMC core components are covered & reinforced as needed in each session.

CLINICAL PATHWAY FOR CARDIAC REHABILITATION

AUBMC CARDIAC REHABILITATION CORE COMPONENTS Assessment & Reassessment Smoking cessation Psychological management Nutritional counseling Diabetes management Exercise training Blood pressure management Lipid management Education

ASSESSMENT & REASSESSMENT Before enrollment Comprehensive medical assessment Risk stratification and 6 minutes walk test In each visit Physical reassessment Metabolic Equivalent Test (METs) for functional capacity assessment. NYHA heart failure staging Dyspnea Borg test during exercise

NUTRITIONAL COUNSELING Dietician is consulted on case by case basis. Sodium restricted diet for heart failure patients. Low animal fat diet for patients with dyslipidemia. Low calorie dietary counseling for obese patients. Diabetic diet prescription for patients with diabetes.

BLOOD PRESSURE MANAGEMENT Blood pressure is taken in each visit. Two readings of blood pressure in different visits to confirm the diagnosis of hypertension. The upper limit for starting hypertension management for patients above 60 years of age is 150/90. For patients younger than 60 years the upper limit for starting management is 140/90. Treatment of hypertension includes: Lifestyle modification Drug therapy including Beta Blockers, ACE I, Calcium Channels Blockers, or thiazide diuretics. (James, 2014)

SMOKING CESSATION Smoking habits and readiness to quit smoking are assessed at each visit. For patients who are not ready to quit, brief motivational interventions are provided. Once the patient is ready to quit he/she is encouraged to set a quit date, and education materials and social support are provided to facilitate the behavioral change.

DIABETES MANAGEMENT Patients with diabetes are screened for potential complications, such as retinopathy, nephropathy, and for hyperglycemia or hypoglycemia episodes. Diabetes therapy is started if HbA1C 6.5%, fasting blood sugar (FBS) 126 mg/dl, 2 hours or random blood sugar 200 mg/dl (ADA, 2014) Diabetic patients are educated about measuring blood sugar, diabetic diet & insulin injection.

LIPID MANAGEMENT Lipid profile shall be obtained on all patients along with liver function test and Creatine Kinase. For dyslipidemia management high potency statins (Atorvastatin 40 mg, or Rosuvastatin 20 mg) are prescribed; if not tolerated, then the patients receive half the doses (Stone et al., 2013)

PSYCHOSOCIAL MANAGEMENT Screening for depression using Patient Health Questionnaire (PHQ-9) as recommended by the American Heart Association. PHQ-9 scores of 5-9 represents minimal symptoms, 10-14 represents minor/mild depression, 15-19 represents moderate depression, and > 20 represents severe depression (Whilliams et al., 2014). Psychiatry consultation for patients with moderate and severe depression is considered. Educational sessions about adjustment to heart disease and stress management.

PSYCHOSOCIAL MANAGEMENT (CONT D) Skill building interventions for lifestyle changes based on self efficacy theory. (Bandura, 1997) Family members shall be included in the psychological interventions. (Whaley et al., 2011) Small group interaction and peer modeling. (Davies et al., 2010)

EXERCISE TRAINING The level of exercise is designed by physical therapist and approved by the medical director. The exercises are tailored to the patient s needs and expectation. Physical exercises include aerobic exercise and/or resistance training. Vital signs are assessed during exercise, noting ischemic changes on the monitor, and the findings are documented on out-patient monitoring form.

EXERCISE TRAINING (CONT D) Aerobic exercises are done three times per week; 20-60 minutes per session at intensity of 50-80% of exercise capacity; and using walking, treadmill, cycling, stair climbing, arm/leg ergometry. Patients are started with warm up, and ended with cool down for each session and are instructed to update the prescriber about tolerance, so exercises are adjusted if needed (Balady et al., 2007)

EXERCISE TRAINING (CONT D) Resistance exercises are done 3 days/week; at 10-15 repetitions per set to moderate fatigue; in 1-3 sets of 8-10 different upper and lower body exercises; and using calisthenics, elastic bands, cuff/hand weights, dumbbells, free weights, wall, pulleys, or weight machines.

EDUCATION The education program shall be tailored to the patient s preference and medical condition. The education sessions shall use case based approach, team based approach, open discussions, and demonstration return-demonstration of procedures depending on the topic addressed and based on adult learning theory. (Knowles, 1990) The cardiac rehabilitation staff, dietician, and psychologist deliver the education sessions according to their specialty. An educational brochure will be provided for patients at discharge from the program.

END OF OUT-PATIENT CARDIAC REHABILITATION PROGRAM The CR medical director and the APN perform final assessment and fill discharge summary form. Patients are followed up once per year by phone by the cardiac rehabilitation medical director or APN after discharge from the rehabilitation program. During follow up, the prescribed exercises and agreed upon life style modifications are reinforced. Any concerns of questions raised by the patient will be addressed.

CARDIAC REHABILITATION EVALUATION

EVALUATION OF THE PROGRAM: QUALITY INDICATORS Cardiac rehabilitation staff competencies. (AACPR, 2014) Rate of uptake to the cardiac rehabilitation program. Rate of adherence to the program (number of sessions attended). Survival and readmission rates of patients at 6 months, and 12 months after enrollment in the program in comparison to non enrolled eligible patients. Percentage of enrolled patients who achieve 50% reduction in LDL-C from baseline; 5 points reduction on the PHQ-9 questionnaire by end of out-patient CR.

CHALLENGES & RECOMMENDATIONS CHALLENGES Financial coverage of the program Patient referrals RECOMMENDATIONS Negotiation with Ministry of Health and insurance companies to provide coverage for the program Advertisements about the program