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3. EXPERIENCE

Chapter 14

Experience With The Comprehensive Programme

Cardiac rehabilitation team, Cardiac Rehabilitation Unit


14.1 Introduction

This chapter presents the experience of the cardiac rehabilitation team and the reflections on comprehensive cardiac rehabilitation in its present form. The reflections are based on the interprofessional discussions during the last year of the project. The project has not systematically evaluated the process by interviewing the cardiac rehabilitation team. The patients, in contrast, have been involved in evaluating the rehabilitation programme during the entire project period and have regularly evaluated the cardiac rehabilitation services in connection with the gathering of experience and adjustment (the form used to evaluate the programme is available in Danish at www.CardiacRehabilitation.dk).

The comprehensive rehabilitation services offered by the Unit include several core components in accordance with the national guidelines (1–3). This chapter describes the clinical experience of the cardiac rehabilitation team with the content of treatment and the organization of clinical practice in the Unit.


14.2 Content Of Treatment

14.2.1 Systematic clinical assessment and referral

Well-functioning cardiac rehabilitation services require that all patients be assessed systematically for referral. In the comprehensive cardiac rehabilitation programme, a nurse independent of the discharge process systematically assesses all patients for the need for cardiac rehabilitation (Chapter 2). In an operational situation, the patients’ suitability for cardiac rehabilitation would most appropriately be assessed as part of the discharge process. An assessment form (a form that can be used at discharge or for outpatient assessment is available in Danish at www.CardiacRehabilitation.dk) can be used to ensure that all aspects of a patient’s condition are assessed systematically.

We find that patients are more motivated to participate in comprehensive cardiac rehabilitation if they are asked to attend an outpatient assessment interview than if they are asked to participate while inpatients. Patients are more clarified about their illness and have determined their need for support after the acute illness period when they attend an outpatient interview. We therefore recommend that patients in the future be referred to outpatient discharge counselling in the Unit when their acute situation has been fully assessed.

The patients we receive at the Unit have been referred one week after discharge, which is equivalent to the referral interval for cardiac rehabilitation for a typical patient after acute myocardial infarction. We have found that referral back to the Unit of patients who have received acute and subacute invasive treatment at other hospitals is not systematic. This referral requires that health personnel have adequate insight into the effects and extent of cardiac rehabilitation services at the local hospital. In the future, effective routines should be implemented that ensure that all patients undergo uniform systematic assessment and referral.

Based on our experience in the Unit,we find a general need for clear referral procedures that indicate the optimum time for referral to cardiac rehabilitation of the broad and heterogeneous group of patients targeted by cardiac rehabilitation services: patients who have had coronary artery bypass grafting or percutaneous coronary intervention, patients with stable ischaemic heart disease or congestive heart failure and patients at high risk for developing ischaemic heart disease.


14.2.2 Individual tailoring of patient programmes, risk factor management and clinical assessment

Patient programmes are individually tailored through individual consultation and subsequent coordination at the interprofessional conference (Chapter 4). This model, in which all professions counsel the patients, strengthens both the individual professions and the interprofessional approach and thereby improves the overall patient programmes.

A nurse coordinated patient programmes in the last part of the project.We believe that rehabilitation could be improved if a nurse consulted the patients at a follow-up discussion during or after the six-week intensive programme as a supplement or alternative to the follow-up clinical assessment with a physician. The nurse can have difficulty in following up on planned initiatives or problems if a follow-up consultation is not scheduled, and patients seldom ask for such a consultation with a nurse.

Striving to achieve pharmaceutical compliance in the comprehensive cardiac rehabilitation has been a great challenge, since many patients are scheduled to take substantial medicine at various times of the day. We used a form for patients’ medicine (see www.CardiacRehabilitation.dk for this form and instructions in Danish), systematically assessed the pharmaceuticals used and updated the records at each follow-up consultation with a physician. Ensuring good pharmaceutical compliance is difficult in the long term.This should be in special focus in the future, since optimum pharmaceutical treatment and good compliance are very important for the overall effect of cardiac rehabilitation.

Coordinating the multifactorial intervention has been very challenging. Various software (PRECARD and HjerteRask) has been used to carry out the complex tasks, but this software was not developed for a cardiac rehabilitation programme. The software has therefore inadequately fulfilled the overall needs of the Cardiac Rehabilitation Unit.The needs during the project period were met using patients’ treatment plans, with manual entry of additional information1 combined with a standard interview guide for the counselling. In the future, cardiac rehabilitation software is needed that can be used as part of individual tailoring and the risk factor management and clinical assessment. Systematic and clear assessment of the cardiac rehabilitation activities for each patient would provide valuable information for evaluation and for continuing development. This registration could also form the basis for a future national clinical database on cardiac rehabilitation. This database could be linked to the Danish Heart Disease Registry (4) and the Danish Clinical Database on Invasive Cardiac Procedures and thereby provide valuable knowledge on cardiac rehabilitation activities at the individual level.


14.2.3 Patient education

The comprehensive cardiac rehabilitation programme has mainly organized patient education as group programmes (Chapter 5). To ensure uniform communication of information, the education is organized based on a standard educational programme and standard materials. Nevertheless, the educator has the autonomy to modify the educational material and to structure the educational sessions based on patients’ desires and needs.

In contrast to our expectations, substantial differences in age may create good dynamics in a group if everyone is allowed to participate.

If several patients in a group have been recommended to lose weight or stop smoking, we find that patients enter into mutual agreements, which promotes motivation. The patients quickly organize themselves and learn how to benefit from one another, which creates a positive group effect. Nevertheless, a negative group effect may arise if one or more patients express opposition to changing lifestyle. These patients may ultimately demotivate a group, and the educator must assess whether such a patient should be transferred to an individual educational programme.

The size of the group strongly influences patient education. The smaller the group, the fewer patients can exchange experience, and a group may rapidly seem very small if a few members do not attend. In contrast, very large groups can create difficulty in taking individual consideration, and less active patients can easily be ignored or have difficulty in participating.

The demand for courses in cardiac resuscitation has been unexpectedly large, and waiting lists have therefore been created. Patients and their family members are very committed in participating in the course, and the family members say that this course has given them confidence that they could act appropriately if they suddenly witness a cardiac arrest. Several patients have further stated that seeing their family members participate actively in the course has made them feel more secure in daily life.

The groups formed in comprehensive cardiac rehabilitation have had various diagnoses because of the broad target group. This heterogeneous composition has mostly created problems in educational programmes. A high-risk patient, for example,may have difficulty in identifying with the problems of a patient with congestive heart failure. This can be solved by offering additional education to patients with special diagnoses: ischaemic heart disease, congestive heart failure and type 2 diabetes or special problems, such as patients with an implantable cardioverter defibrillator or pacemaker and patients with auricular fibrillation. This has not been possible in the comprehensive cardiac rehabilitation programme, however, because the patient flow was relatively low during the project period. A larger patient flow in an operational situation would allow more homogeneous groups to be created.


14.2.4 Exercise training

The Cardiac Rehabilitation Unit asks all patients to participate in an intensive supervised exercise training programme over six weeks (Chapter 6).

We were surprised at how rapidly patients take responsibility for exercise training, assisted by heart rate monitoring.We find that the heart rate monitoring and individual evaluation encourages the patients to exercise. Nevertheless, the patients have expressed the desire for more comprehensive exercise training than that offered in the Unit, which is based on activities that can easily be transferred to daily life. We have therefore bought balls for balance and equilibrium exercises and walking sticks and aerobics elastics to train the muscles of the upper body extremities.

Patients with congestive heart failure and with ischaemic heart disease can easily exercise together and carry out everyday activities such as cycling,walking and climbing stairs if the exercise training is monitored individually and the necessary precautions are taken (Chapter 6).

The physical therapist has registered symptoms, injuries and accidents in the supervised exercise training. The 389 patients exercised for about 6000 hours during the project period without any form of adverse cardiac event.

By closely cooperating with the physical therapist, the rest of the cardiac rehabilitation team has gained insight into the methods of the physical therapist and the opportunities to improve patients’ level of physical functioning with relatively little effort. The clinical team observes how pleased patients are to be getting physical exercise and obtains insight into how much patients can manage in daily life.


14.2.5 Support for changing diet

The Unit has organized support for changing diet as individual counselling with the dietitian and group cooking classes (Chapter 7). The patients seldom fail to attend dietary counselling in comprehensive cardiac rehabilitation, in contrast to a traditional dietary consultation at a hospital. The probable reason is that the patients feel that dietary intervention is a key component of the overall treatment.

Many patients are sceptical when they attend the cooking classes. Several are selfconscious about being educated on how to cook; others are sceptical about whether healthy food really tastes good. This especially arises when the group is eating for the first time, as many patients say they are surprised by how good the food tastes. Several patients then subsequently report that they use the heart-healthy recipes for both daily meals and when entertaining guests. The patients call the dietitian long after leaving the cardiac rehabilitation programme to get inspiration for new recipes. The cardiac rehabilitation team is thus convinced that cooking classes give many patients the courage to prepare different types of meals than those they usually prepare; experience shows that this is a difficult process.

The close cooperation with the dietitian gives the rest of the cardiac rehabilitation team insight into the significance of diet and the opportunities to motivate patients to change their diet; especially physicians have traditionally not been aware of this. The cardiac rehabilitation team also obtains insight into the professional fields and methods of the dietitian.


14.2.6 Support for smoking cessation

Support for smoking cessation in the comprehensive cardiac rehabilitation programme includes individual counselling with a nurse, smoking cessation counselling in groups and individual smoking cessation programmes (Chapter 8).

It is decisive that the patients receive uniform information on the important of smoking and quitting as part of preventing disease and treating heart disease. Patients who are told that they are healthy in connection with invasive treatment are less motivated to stop smoking. Health personnel should strive in the future to make uniform all information as well as attitudes towards the importance of quitting for preventing and treating heart disease.

Getting patients to quit smoking is very difficult. When patients start to smoke again, practitioners tend to lose faith in the utility of intervention. Nevertheless, practitioners must maintain that quitting smoking, like all other changes in lifestyle, is a process, and many attempts may be required to change lifestyle in the long term.

Group education in which patients are at very different phases in the cycle of motivation may be difficult. Many of the smoking cessation programmes in the comprehensive cardiac rehabilitation programme have therefore been carried out individually.

Smoking cessation counselling in groups requires clear agreements with the patients at the first meeting stipulating that they must explicitly indicate whether they are ready to stop smoking. This avoids the ambivalence of individual patients from adversely affecting the rest of the group. Many patients who thought they were motivated to stop smoking lose courage at the start of the group counselling. These patients should instead be offered individual health counselling.

Patients tend to leave the group counselling if they have started smoking again. This can be avoided if the smoking cessation counsellor emphasizes at the first meeting that most smoking cessation programmes include relapse.


14.2.7 Psychosocial support

The structured psychosocial intervention of the comprehensive cardiac rehabilitation programme includes individual therapeutic counselling, group intervention, treatment of anxiety and depression, a 24-hour helpline and social support (Chapter 9).

Patients’ crisis period can be reduced considerably if they have the opportunity to talk to a professional about their situation early in this period. This requires the interprofessional clinical team to have through knowledge of crisis situations and crisis management.

Some patients treated in comprehensive cardiac rehabilitation are referred to detailed assessment by a liaison psychiatrist. Telling patients that they require psychiatric assessment may be difficult. Such patients often get concerned and defend themselves by saying that their situation is not that serious and that they do not consider themselves as mentally unstable. The patient should therefore be told that many people get anxiety and depression in connection with acute illness and that this can and should be treated just like the other sequelae of heart disease.

Informal discussions between the patient and professionals and among the patients play an important role in psychosocial support. The meal that is part of the cooking classes has an important social aspect, and during the exercise training the patients bond to the extent that several of the groups have continued group exercise training voluntarily after the comprehensive cardiac rehabilitation programme ended. In the future, the Cardiac Rehabilitation Unit should support the continuation of these spontaneously arising groups with the aim of continuing psychosocial support and maintaining exercise training in phase III of the programme.

Family members (especially spouses) can demonstrate the same reaction as the patient, and the patient and family members can influence one another negatively. Some family members react more strongly to the illness than the patient does. Many patients report that family members become afraid and insecure in connection with activities of daily living that the patients previously managed without problems. Including family members in education and individual counselling is important, perhaps after the patients have had an independent opportunity to begin to cope with their new role.

In evaluating treatment services, patients strongly emphasize the 24-hour telephone access to the Cardiac Rehabilitation Unit. The significance patients attribute to this function contrasts with the fact that the helpline is seldom used outside regular business hours. Implementing a 24-hour helpline requires very few additional resources compared with the security this creates for the patients.

The fact that a social worker has participated in the interprofessional conference and has assisted in advising on the opportunities for support from social services has been very important for the overall cardiac rehabilitation efforts. The clinical team considers that acquiring expertise in this field would be an impossible challenge for them, since legislation and practice change often.


14.2.8 Supplementary diabetes module

The diabetes module in the comprehensive cardiac rehabilitation programme includes screening for type 2 diabetes, individual diabetes counselling, group education and meetings on impaired glucose tolerance (pre-diabetes) (Chapter 11). Systematically screening for diabetes in the programme has revealed surprisingly many patients with newly discovered diabetes (5). Diabetes screening can be carried out without great difficulty in a cardiac rehabilitation programme. The Cardiac Rehabilitation Unit has tackled the logistical problems that are often mentioned as a barrier using computer software.

Patients with type 2 diabetes are known to be more severely ill than non-diabetics. Diabetic patients must therefore be monitored more closely and be treated more intensively to achieve the strict treatment goals in cardiac rehabilitation. This often results in increased use of multiple pharmaceuticals, which creates problems with compliance.

Intervention in the lifestyles of patients with diabetes is an even greater upheaval than for non-diabetics. For example, similar to other people, patients with type 2 diabetes should anticipate gaining weight when they stop smoking. Many patients who start taking or increase the dosage of certain anti-diabetes pharmaceuticals when they quit smoking gain even more weight, which makes quitting even more difficult over time. Patients with heart disease often follow the recommendation of reducing intake of fat and sweets and eating more fruit, but patients with diabetes also need to limit their fruit consumption.

Many patients with diabetes have sexual problems. Diabetic impotence can successfully be treated with pharmaceuticals. Practitioners should discuss sexual problems with both men and women.

The Cardiac Rehabilitation Unit has attempted to meet the established treatment goal for glycaemic control. Nevertheless, achieving the goal and maintaining the optimal level for 12 months has been difficult. Achieving and maintaining the treatment goal requires very close follow-up and continual further training of the clinical team.


14.2.9 Cooperation with primary health care

The comprehensive cardiac rehabilitation programme has not taken special initiatives to strengthen cooperation with primary health care other than routinely forwarding comments to the general practitioner after the programme ends at the 12-month physician consultation. In addition, during the long programme the general practitioner is informed of changes in pharmaceutical administration through the patient’s medicine form.

The transfer to primary health care poses a great risk of losing the treatment effects achieved. Similarly, the patients risk experiencing a lack of continuity in overall health care.

Cooperation with primary health care needs to be in focus in the future to ensure the patients a coherent treatment programme and to maintain the treatment effects achieved.


14.3 Organization

14.3.1 Interprofessional organization and performing of tasks

The clinical practice of the comprehensive cardiac rehabilitation programme is organized based on the principles of an interprofessional approach and comprehensive treatment ideology (Chapter 12).

The programme is optimized when the various professional approaches and competencies are used in a coherent programme in which the tasks performed are coordinated. Nevertheless, practising interprofessional cooperation can be extremely difficult. One prerequisite is common definitions within the interprofessional team.

The interprofessional rehabilitation programme places very high demands on profession- specific competence. If a high level of profession-specific competence is not ensured by hiring and training highly qualified staff, the interprofessional group risks acquiring an approach in which everyone is merely superficially familiar with the other professions and the advantages of a strong profession-specific approach thus disappear.This project has emphasized the importance of continual further education and training for each profession together with further education and special training within cardiac rehabilitation with the aim of ensuring professional excellence within all components of rehabilitation.

Complying with the dual demands of profession-specific excellence and an interprofessional approach can be difficult for practitioners. When professionals are discussing treatment strategy, the profession that historically has achieved the highest status, physicians, will often dominate, since the entire clinical team has been trained in a culture in which physicians decide treatment. The requirement for dialogue means that discussion on profession-specific excellence and an interprofessional approach has to be prominent, and the well-known loyalty to one’s own profession can be severely strained. Interprofessional cooperation is a process that requires continual follow-up and supervision, especially since the Cardiac Rehabilitation Unit regularly employs new personnel with new values.

An interprofessional approach poses great demands on the priorities and overview of management in ensuring coherent programmes for patients by involving and coordinating the various professional approaches while maintaining and developing profession- specific excellence.

Ensuring common attitudes towards participating in interprofessional cooperation, including both specific tasks and organizing and coordinating practice, is important in employing staff and in setting priorities in organizing clinical practice.

Challenges in cooperation can especially arise in the following situations: uncertainty about carrying out tasks, disagreement on the division of tasks and responsibility, disagreement on goals and assessment criteria, differences in how involved the staff are in the programme and differences in the forms of management and cooperation desired by staff. In the future organization of cardiac rehabilitation, the management should take positions on and involve staff actively in these challenges and establish a structure for these.


14.3.2 Joint electronic patient records

The clinical team has used a joint electronic patient record, a cornerstone of an interprofessional approach to performing tasks. Implementing an electronic patient record unexpectedly became a prominent subproject and required considerable staff resources. Similar to other settings (6), introducing electronic patient records has had several or-ganizational effects and sparked a need for redefining the roles and functions of each profession.We found that successfully implementing electronic patient records places greater demands on organizational culture than on the software used. The Cardiac Rehabilitation Unit implemented electronic patient records in connection with a comprehensive change in the organization of treatment. This turned out to be a good time for such a thorough change of established work routines since the clinical team was very open and willing to change.

A joint information base developed through common systematic information collection has turned out to be decisive for coordinating an interprofessional programme. Finally, the joint information base is an important prerequisite for assuring a high-quality coherent programme for each patient.

The patients are actively involved in using the Unit’s electronic patient records. The patients are initiated into viewing the electronic patient records from the initial consultation with a physician, at which they are informed that they may read and comment on the notations.We find that most patients feel secure about this and are quite attentive, similar to the experience from using electronic patient records in general practice. Nevertheless, a few mostly elderly patients have expressed uncertainly about rehabilitation activities because of the lack of a paper record.


14.3.3 Physical setting

All components of cardiac rehabilitation are located at the Cardiac Rehabilitation Unit. This physical unity plays a great role in interprofessional cooperation, since daily in-formal contact allows the professions to exchange experience. The daily contact also reduces the cultural barriers to cooperation.

When the Cardiac Rehabilitation Unit was founded, one emphasis was access to showering facilities, which cost considerable money to build. Nevertheless, few patients use these facilities.

It has been very important that the kitchen is designed so that it can be used for both theoretical and practical education. Older patients and patients with congestive heart failure may have difficulty standing up during an entire cooking session, and these patients benefit greatly from the ergonomically adjustable stools. A kitchen must be designed based on the fact that many patients in cardiac rehabilitation are overweight and therefore take up more space than people of normal weight.

The cardiac rehabilitation programme was installed in suitable offices, but the accessibility was poor. In acute situation, access conditions must comply with existing standards for access for disabled people for safety reasons and to accommodate the group of patients with severely reduced functioning.


References

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

(2) Hildebrandt P, Gřtzsche CO. Akut koronart syndrom. Retningslinjer for diagnostik og behandling [Acute coronary syndrome. Guidelines for diagnosis and treatment]. Copenhagen, Danish Society of Cardiology, 2001 (www.dadlnet.dk/klaringsrapporter/2001-03/2001-03.HTM, accessed 22 March 2004): 1–28.

(3) Working Group of the Danish Secretariat for Clinical Guidelines. Referenceprogram for behandling af patienter med akut koronart syndrom uden ledsagende ST-segmentelevation i ekg’et [Clinical guidelines for the treatment of patients with acute coronary syndrome without accompanying ST-segment elevation in electrocardiogram]. Copenhagen, Danish Secretariat for Clinical Guidelines, 2002.

(4) Videbaek J, Madsen M. Hjertestatistik 2000–2001 [Statistics on heart disease in Denmark, 2000–2001]. Copenhagen, Danish Heart Foundation and National Institute of Public Health, 2002.

(5) Soja AM, Zwisler ADO, Melchior T, Hommel E. Abnormal glucose metabolism among patients attending cardiac rehabilitation. The DANSUK study. Annual Meeting of the American Association of Cardiovascular and Pulmonary Rehabilitation, Kansas City, Missouri, 13–16 October 2003.

(6) Svenningsen S. Electronic patient records and medical practice. Reorganization of roles, responsibilities, and risks. Dissertation. Copenhagen, Copenhagen Business School, 2003.


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© Cardiac Rehabilitation, Department of Cardiology Y, H:S Bispebjerg Hospital