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3. EXPERIENCE


Chapter 13

Project Development And Patient Material

Ann-Dorthe Olsen Zwisler


13.1 Introduction

The comprehensive cardiac rehabilitation programme and the Cardiac Rehabilitation Unit at Bispebjerg Hospital were founded as a project in late 1999 in accordance with the recommendations of a local working group on reorganizing cardiac rehabilitation (1). The cardiac rehabilitation project has undergone a process of development, and the staff have gathered considerable experience in clinical practice. This chapter describes the main aspects of the development process and the patient material. The development of the project is described in detail elsewhere (2).


13.2 Project Development

The comprehensive cardiac rehabilitation project has gone through several development phases in its three years that are typical of reorganization (3;4). The figure on page 158 outlines the individual phases and traces them chronologically.


13.2.1 Project phases

Founding
The staff, who were recruited through internal selection (Chapter 12 describes the joint training programme), broadly supported the founding of the comprehensive cardiac rehabilitation programme. All staff helped to furnish the offices (more details available in Danish at www.cardiacrehabilitation.dk) and to establish practical procedures corresponding to the overall guidelines (1;5). The methods and procedures were tested on three pilot groups and adjusted based on patients’ evaluation.

Project phases in the comprehensive cardiac rehabilitation programme
Illustration of Project phases in the comprehensive cardiac rehabilitation programme

Gathering experience
The project began in March 2000. Considerable organizational and practical experience was obtained in comprehensive cardiac rehabilitation in the first year based on patient material equivalent to full operation. The need to adjust the project in relation to full operation was identified, and the project was adjusted in several ways.

Adjustment
The programme was carefully adjusted in relation to the scientific protocol (available in Danish at www.CardiacRehabilitation.dk), since the programme has been subject to the premises of a scientific study throughout the project period.

The most extensive adjustments were associated with the individual tailoring of patient programmes, which solely included a consultation with a physician at the start of the project. The consultation with a physician did not provide the staff with adequate knowledge of the patients’ motivation, resources and barriers, and the treatment goals were not clear to the interprofessional team of practitioners. Based on the interprofessional discussions, the rehabilitation programme was extended to include individual counselling with a physical therapist, clinical dietitian and nurse. The standardized interview guides (available in Danish at www.CardiacRehabilitation.dk) were prepared to ensure uniform information content for the individual counselling, and the focus for the interprofessional conference was changed to emphasize the individually tailored rehabilitation programmes and establishing goals and planning clinical assessment. This adjustment allowed the team of practitioners to get to know the patients better, and the patient programmes could thereby be targeted and tailored better.

During the adjustment period, the Unit decided that all patients would take an introductory test of aerobic functioning to individually tailor the exercise training and a follow-up aerobic test and counselling with a physical therapist at 3 and 12 months. The adjustment improved the focus on individual exercise, following up the effects of exercise, biofeedback and adjustment.

Experience from the first year showed that the treatment of patients with type 2 diabetes did not comply with the current guidelines (6), and the team of practitioners suspected that type 2 diabetes was being underdiagnosed among patients in the programme. The rehabilitation programme was adjusted by focusing on type 2 diabetes, and cardiac rehabilitation was extended to a special diabetes module (Chapter 11).

Experience with organization in the first year showed that the daily management of the interprofessional team needed to be strengthened. The purpose of this change was to ensure closer follow-up of the comprehensive performing of tasks, which had not yet become firmly established, and to meet the staff demand for clearer guidelines for internal and external cooperation. As several professions are involved in treating patients, the tasks and division of labour needed to be defined clearly in relation to treating patients and in relation to administrative and technical tasks. The cardiac rehabilitation team found that each profession tends to focus on its profession instead of focusing on the interaction with other professions and how this can contribute to the comprehensive efforts. The significance of an integrated approach therefore needed to be discussed regularly in relation to the profession-specific activities.

Consultants from Bispebjerg Hospital’s Department of Development, Education and Training have monitored and supervised the Unit head and staff during the process of development. Two seminars were held during the project period: one in connection with the founding of the comprehensive cardiac rehabilitation programme and one in connection with the adjustment of the rehabilitation programme.


13.2.2 Patient material

During the three-year project period, 389 patients received comprehensive cardiac rehabilitation within the Unit; 86% of these carried out the intensive programme. The mean age was 63.4 years, and 37% were women. Twelve percent had congestive heart failure, 58% had ischaemic heart disease and 30% had a high risk of ischaemic heart disease. Twenty percent had known type 2 diabetes. Forty-seven per cent of the patients in the comprehensive cardiac rehabilitation programme lived alone at the start of the rehabilitation programme, and 20% were on the labour market.

Scientific articles will present information on patient attendance, patient evaluation of the cardiac rehabilitation services, the resources used and cost calculations and will calculate the effects and analyse the health economics of the programme in accordance with the evaluation model for the project (available in Danish at www.CardiacRehabilitation.dk).


References

(1) Olsen AD, Degn L, Sigurd B. Hjerterehabilitering og -forebyggelse på Bispebjerg Hospital [Cardiac rehabilitation and prevention of heart disease at Bispebjerg Hospital]. Copenhagen, Bispebjerg Hospital, 1997.

(2) Zwisler ADO. DANREHAB-studiet. Efterbehandlingstilbud til patienter udskrevet fra en hjerteafdeling. Status [The DANREHAB study. Rehabilitation services for patients discharged from a department of cardiology]. Copenhagen, Bispebjerg Hospital and National Institute of Public Health, 2002.

(3) Enderud H. Beslutninger i organisationer [Decisions in organizations]. 7th edn. Copenhagen, Fremad, 1986.

(4) Rasmussen NK, Poulsen J. Evaluering af forebyggende sundhedsarbejde [Evaluation of diseasepreventive health activities]. In: Kamper Jørgensen F, Almind G, ed. Forebyggende sundhedsarbejde [Disease-preventive health activities]. 4th edn. Copenhagen, Munksgaard Danmark, 2003: 246–251.

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

(6) Beck-Nielsen H, Henriksen JE, Hermansen K, Madsen LD, Olivarius NF, Mandrup-Poulsen TR et al. Type 2-diabetes og det metaboliske syndrom – diagnostik og behandling [Type 2 diabetes and the metabolic syndrome – diagnosis and treatment]. Ugeskr Laeger 2000; 162(suppl 6): 1–36.


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