2. METHODS

Chapter 12

Organizing Interprofessional Clinical Practice

Lone Schou & Ann-Dorthe Olsen Zwisler

12.1 Introduction

The clinical practice in the Cardiac Rehabilitation Unit is organized based on the fundamental principles of an interprofessional approach and a comprehensive treatment ideology in accordance with existing guidelines (1–4).This chapter describes the structural and organizational conditions in the Cardiac Rehabilitation Unit.

12.2 Purpose

The purpose of an interprofessional form of organization is to ensure that the activities within the seven components of treatment are coordinated with the aims of ensuring an optimal rehabilitation programme for each patient and of achieving the treatment goals.<

12.3 Staff

12.3.1 Organization

The Cardiac Rehabilitation Unit is organizationally under the Department of Cardiology, Centre for Internal Medicine. A physician under the head of the Department of Cardiology heads the Unit and is responsible for daily operations. The Unit is organized with a flat management structure based on the principles of an organization carrying out this type of project.

The Unit head has numerous administrative and clinical tasks. The Unit head takes responsibility for ensuring that patients are treated in accordance with the established goals and that the comprehensive rehabilitation programme is coordinated satisfactorily. The Unit head ensures daily operations in cooperation with the interprofessional staff and takes responsibility for ensuring an environment in which interprofessional cooperation functions optimally both internally and externally. The Unit head is also responsible for ensuring that all staff are trained and for team-building, such that all staff are working towards the same goals. The Unit head participates in the conference of physicians in the Department of Cardiology each morning and in meetings of department heads.

12.3.2 Staff composition and qualifications

The core team in the Cardiac Rehabilitation Unit comprises the following positions (numbers relative to full time): 0.8 physicians, 1.0 nurse, 1.0 physical therapist, 0.5 clinical dietitians, 1.0 secretary and 1.0 receptionist.

The peripheral team includes a social worker, who participates in all interprofessional conferences. This team also includes a liaison psychiatrist who does not participate in interprofessional conferences, and the Unit cooperates closely with the Department of Psychiatry in the form of regular education and supervision.

The Unit staff require great professional and personal independence, since each profession is responsible for its own field. The functions of all positions in the Unit have been detailed in writing (available in Danish at www.CardiacRehabilitation.dk), including the qualifications required, job functions and areas of responsibility.

All staff are required to have specialized education within their profession. The staff are required to have specialized knowledge within cardiology and experience in treating patients with heart disease since the patients in rehabilitation have complicated cases of heart disease.

Educating patients and their families is a component of rehabilitation, and the ability of each practitioner to communicate knowledge on heart disease, influence attitudes and promote changes in lifestyle is decisive for the success of each patient’s rehabilitation programme. The staff must therefore have experience in adult education and motivational counselling techniques and be motivated to take further education or training on the theoretical aspects of adult education and behavioural change, communication and lifestyle intervention. Since the Unit is also engaged in scientific research, all professions must also be given the opportunity for further education and continual updating within science.

The staff preferably have experience with interprofessional cooperation and problemsolving. The approach with an interprofessional organization places great demands on the staff to be oriented towards and committed to development and change. Finally, the staff should fundamentally respect the work of all professions.

12.4 Interprofessional Cooperation

The interprofessional approach of the Cardiac Rehabilitation Unit is based on the premise that decisions on the goals of treatment should be influenced by the insight of several professions and a common framework. This form of organization requires that practitioners both excel in their own profession and be skilled in an interprofessional approach. Practitioners should begin with and appreciate their own professional interpretation of each situation but also enter into dialogue and be critical of their own professional views (5).

The staff attended team-building and training courses taught by organizational psychologists to ensure a good foundation for an interprofessional approach. The staff have focused on developing communication skills, profession-based and interprofessional supervision, developing a common culture and giving priority to professional and social interaction.

The staff have participated in the patient services offered by other professions to obtain insight into an interprofessional approach and have regularly been updated within the individual components of rehabilitation through extended staff meetings and interprofessional conferences.

12.5 Organizing Clinical Practice

The Cardiac Rehabilitation Unit strongly emphasizes that staff resources should be used optimally and that the Unit should be a flexible workplace that can meet the needs of each individual staff member.

Clinical practice is organized with the opportunity for flextime at the beginning and the end of the working day. Patient consultation is scheduled between 0830 and 1530. Time before and after this is used for administrative tasks. An interprofessional conference is scheduled weekly and a staff meeting every two weeks. The work schedule accounts for the availability of staff and offices and the complex integration of individual schedules and several parallel group sessions for six weeks (see www.CardiacRehabilitation.dk for the work schedule (in Danish) and a description of the schedule).

The weekly interprofessional conference discusses the tasks of the coming week, appointments and planned absence with the aim of carrying out tasks optimally. In addition, the conference carries out long-term planning and adaptation.

12.6 Physical Setting

All treatment components are located in the Cardiac Rehabilitation Unit, which is separate from the Department of Cardiology. The fact that the Unit is in one location is decisive for treatment and gives patients the sense that the individual components are coordinated. Similarly, the daily formal and informal contact between the various professions is very important for interprofessional cooperation.

The physical separation from the acute inpatient ward of the Department of Cardiology is in accordance with the natural progression of patients from the inpatient ward during the acute phase to an outpatient role in early rehabilitation but physically separated from the acute inpatient ward. This de-emphasizes the person’s role as a patient, and the patients takes joint responsibility for treatment.

Reception area: The reception area is the command centre of the Cardiac Rehabilitation Unit. Its most important function is receiving patients and coordinating each patient’s programme. The reception area includes a counter; workplaces with computers, telephones and telefax; and archives.

Waiting room: The waiting room is located in the centre of the Unit and has chairs for patients and family members. This room has relevant magazines and information material, hot and cold sugar-free drinks and fruit.

Toilet and bathroom: The toilet and showering facilities are located near the waiting room, with facilities for both men and women. Nevertheless, few patients use these facilities.

Consultation rooms: The Unit has three consultation rooms; each has a computer, telephone, examination table and sphygmomanometer.

Weighing: Patients are weighed in a small, independent room that has a scale everyone uses to avoid differences because scales need to be calibrated. The scale is electronic and is calibrated regularly. It can weigh patients up to 200 kg, and the display is at chest height so that very obese patients can visually follow their progression in weight, including any loss.

Testing room: A consultation room has a testing cycle and examination table to test aerobic functioning.

Exercise facilities: The aerobics room is 40 m2 and has space for about eight people, a music system, parallel bars, wall bars, mats, balls and other equipment. Next to the aerobics room is an exercise room with cycles, a computer station and a blackboard for educational purposes. The main stairway in the Unit to the fourth floor is part of the exercise facilities. The aerobics and exercise rooms have telephones in case patients become acutely ill in connection with exercise and testing.

Kitchen: The Unit has a kitchen in which the dietitian and the patients and their families cook. The kitchen is furnished in accordance with the hygienic principles of Bispebjerg Hospital and is ergonomically designed. The kitchen has two cooking islands; each has a sink, oven and cooking equipment. There is a refrigerator–freezer, a dishwasher and a blackboard.

Dining and consultation room: The dietitian’s consultation room has a table used for meetings and for eating the meals prepared in the cooking classes. This room has instructional equipment and a workplace with a computer and telephone.

Group room: Patients receive group education in a room designed for 12 people with plenty of space, a bright atmosphere and a window. This room has a table, chairs, computer with a projector, whiteboard, screen, overhead projector and television with videocassette player.

Workplaces: The workplaces in the Unit can accommodate any staff member; each has a computer with access to the Internet, an intranet and the nationwide hospital information system (Green System) in all rooms. Each staff member has a mobile chest of drawers.

Storage depot: The Unit has a storage depot with storage space, a printer, a photocopier, a locked medicine cabinet and other equipment.

12.7 Safety

Physical activity can trigger adverse cardiac events. Nevertheless, the risk is low in supervised activities (6).There is little experience with exercise training among patients with congestive heart failure, who have increased risk for life-threatening arrhythmia, but if the principles related to exercise intensity are followed, the risk of exercise training among this group of patients is considered minimal (7). Denmark has no safety recommendations for physical activity among patients with heart disease, and both departments of cardiology and countries vary widely in their safety routines (8).

Despite the assessed low risk of exercise, the Cardiac Rehabilitation Unit gives high priority to patient safety. The Unit always requires two staff members to be present whenever patients are in the exercise rooms. All staff have been trained in basic cardiac resuscitation and the physicians and nurses in advanced cardiac resuscitation. An instructor in cardiac resuscitation trains staff every six months. The Unit has equipment for and instructions for cardiac resuscitation (available in Danish at www.CardiacRehabilitation.dk).

Cardiac resuscitation cart: A cart including a defibrillator and other cardiac resuscitation equipment is located in the waiting room. Pharmaceuticals for cardiac resuscitation are in the medicine cabinet for safety reasons (the medicine present is available in Danish at www.CardiacRehabilitation.dk). A nurse checks the defibrillator weekly. The defibrillator can be used anywhere in the Unit with or without an electrical outlet.

Pharmaceuticals: In accordance with the guidelines of the Copenhagen Hospital Corporation, pharmaceuticals are kept in a locked medicine cabinet.The range of drugs available meets the needs of the Unit.There is medicine to treat all types of acute illness, such as cardiac arrest, heart and lung disease and acute diabetic conditions. There are various analgesics and a broad selection of cardiac pharmaceuticals for testing and starting treatment. Since smoking cessation is part of treatment in the Unit, there are many nicotine replacement products. A nurse checks all pharmaceuticals regularly for date of expiry and adjusts them in accordance with current guidelines.

Acute illness: The Unit has the following procedure for congestive heart failure, tachycardia, syncope, chest pain and other acute illness. 1) The physician and the care staff in the Unit are summoned and any necessary treatment is initiated. 2) The physician assesses whether the patient needs to be transferred to intensive care or the acute inpatient ward. 3) The physician accompanies the patient in the transfer.

Cardiac arrest: The Unit has the following procedure for cardiac arrest. 1) The alarm is sounded. 2) Resuscitation and treatment are initiated. 3) The patient is transferred to intensive care. 4) The physician accompanies the patient in the transfer.

Fire: All staff are trained in extinguishing fires, and the Unit has fire blankets, powder extinguishers and water extinguishers. The Unit has the following procedure for fire. 1) The alarm is sounded. 2) People who are immediately threatened are evacuated. 3) All doors and windows are closed. 4) The fire is extinguished if possible. 5) Firefighters are informed on arrival of the location and extent of the fire.

Safety procedures and the physical setting comply with the Working Environment Act (9) and the standards of the Copenhagen Hospital Corporation, which are based on international standards (10).

References

(1) Danish Heart Foundation and Danish Society of Cardiology. Rehabilitering af hjertepatienter. Retningslinjer [Cardiac rehabilitation. Guidelines]. Copenhagen, Danish Heart Foundation, 1997.

(2) Wood D, De Backer G, Faergeman O, Graham I, Mancia G, Pyorala K. Prevention of coronary heart disease in clinical practice: recommendations of the Second Joint Task Force of European and other Societies on Coronary Prevention. Atherosclerosis 1998; 140(2): 199–270.

(3) Wenger NK, Froelicher ES, Smith LK, Ades PA, Berra K, Blumenthal JA et al. Cardiac rehabilitation as secondary prevention. Agency for Health Care Policy and Research and National Heart, Lung, and Blood Institute. Clin Pract Guidel Quick Ref Guide Clin 1995; (17): 1–23.

(4) Giannuzzi P, Saner H, Bjornstad H, Fioretti P, Mendes M, Cohen-Solal A et al. Secondary prevention through cardiac rehabilitation: position paper of the Working Group on Cardiac Rehabilitation and Exercise Physiology of the European Society of Cardiology. Eur Heart J 2003; 24(13): 1273–1278.

(5) Seemann J. Distriktspsykiatrien i et organisatorisk spændingsfelt [District psychiatry in an organizational field of tension]. In: Blinkenberg S, Vendsborg PB, Lindhardt A, Reisby N, ed. Distriktspsykiatri. En lærebog [District psychiatry. A textbook]. Copenhagen, Hans Reitzels Forlag, 2002.

(6) Van Camp SP, Peterson RA. Cardiovascular complications of outpatient cardiac rehabilitation programs. JAMA 1986; 256(9): 1160–1163.

(7) Recommendations for exercise training in chronic heart failure patients. Eur Heart J 2001; 22(2): 125–135.

(8) Vanhees L, McGee HM, Dugmore LD, Schepers D, van Daele P. A representative study of cardiac rehabilitation activities in European Union Member States: the Carinex survey. J Cardiopulm Rehabil 2002; 22(4): 264–272.

(9) The Working Environment Act. Act No. 784 of 11 October 1999. Copenhagen: Danish Working Environment Authority, 1999 (www.at.dk/sw8800.asp, accessed 22 March 2004).

(10) Joint Commission International standards for hospitals. 2nd edn. Oakbrook Terrace, IL: Joint Commission International, 2003.