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The walk to save: benefits of inpatient cardiac rehabilitation.

Patient immobilization during hospitalization can cause multiple complications, including atelectasis, pneumonia, blood clots, and hemodynamic instability (Atkins & Kautz, 2015). Muscle deterioration occurs rapidly. Long-term ventilator use has been associated with functional and cognitive decline, resulting in short-term and/or long-term disability and poorer quality of life after hospital discharge (Vollman, 2013). Immobility can cause 5% loss of muscle mass daily, which is worse in older adults whose functional ability decreases within 2 days of hospitalization (Freeman & Maley, 2013). Functional deterioration leads to risk for increased morbidity, higher hospital readmission rates, and need for prolonged physical therapy services after hospitalization (Adler & Malone, 2012).

Ventricular remodeling occurs as a result of cardiac injury from myocardial infarction (MI); this physiologic change causes risk for lethal arrhythmias and mortality, especially in the presence of low ejection fraction and tachycardia at rest (Santos-Hiss et al., 2011). In their study of the effects of progressive ambulation on heart rate variability following acute MI, SantosHiss and colleagues concluded progressive exercise improved vagal tone and decreased sympathetic and parasympathetic imbalance at rest. The improved vagal tone in turn provided protection against arrhythmias and cardiovascular complications from ventricular remodeling. Findings indicated progressive activity was safe.

Physical activity not only prevents possible complications but also improves exercise tolerance, as it allows physiological adaptations to occur. One of the first observations on adaptation of the cardiovascular system to physical activity was made in 1768 by Herbeden, who noted the activity of chopping wood for 30 minutes daily improved symptoms of angina (as cited in de Macedo et al., 2011). However, this finding was discounted for many years. Bedrest was common therapy following a cardiac event during the 1930s, progressing to chair therapy in the 1940s. Activity progressed to light walking after 4 weeks in the 1950s. Research in the late 1950s changed the dynamics of rehabilitation strategies and laid the groundwork for cardiac rehabilitation programs used today (Singh & Schocken, 2015). Formal cardiac rehabilitation programs soon were established and have continued to expand (de Macedo et al., 2011). The American College of Sports Medicine (ACSM, 2014) found early ambulation contributes to hospital length of stay less than 24 hours for uncomplicated percutaneous coronary intervention and 5 days for uncomplicated MI and coronary artery bypass graft surgery.

Despite the benefits of activity and the adverse effects of prolonged immobility, Vollman (2013) noted staff perceived unstable vital signs (59%) and low respiratory or energy supply (46%) to be barriers to progressive mobility. Hemodynamic instability and altered mental status, as well as vasopressor use and ventilator support, also have been recognized as significant hindrances to progressive ambulation (Freeman & Maley, 2013). However, research has shown progressive activity is safe and should be used. According to Freeman and Maley, "Failure to mobilize patients early and to prevent postoperative complications by limiting their mobility and independence is essentially a disservice to the patient. Early mobility must be a high priority of all ICU patients" (p. 82). Staff education to promote safety and efficacy of progressive ambulation is thus essential (Vollman, 2013).

Progressive Ambulation

Progressive ambulation is defined as beginning out-of-bed activities with progression from sitting to standing, with eventual hallway ambulation (Singh & Schocken, 2015). Before beginning ambulation, the patient should be assessed carefully. A detailed review of the patient history should include recent progress notes regarding current status, procedure notes, baseline and previous activity level, and medication list. The patient's telemetry history should be evaluated and vital signs obtained. If the patient is oxygen-dependent, a portable oxygen tank will be needed during exercise (Freeman & Maley, 2013). Mean arterial pressure, positive end-expiratory pressure, use of vasopressors, and agitation/sedation measures should be evaluated to determine the appropriateness of activity. Physiologic responses should be monitored accordingly (Vollman, 2013).

Progressive ambulation following a cardiac event or cardiac surgery should begin as soon as ambulation is safe. According to the ACSM (2014), self-care activities and in-bed activities should be performed initially following acute MI. When hemodynamically stable, the patient should begin progressive ambulation by walking 50-500 feet with assistance and ultimately walk the hallway independently two to four times per day.

Following open-heart surgery, the patient should begin progressive mobility in the surgical intensive care unit (Freeman & Maley, 2013). Within 8 hours of admission, critically ill patients should be assessed to determine the appropriate type of mobility. They then should be assessed at least daily to plan activities before out-of-bed mobility occurs. In the intensive care or critical care setting, mobility measures should include in-bed activities as well as ambulation (Vollman, 2013).

Early ambulation starts with in-bed mobilization activities. Opportunities for in-bed activities include head-of-bed elevation, turning and rotation, range of motion exercises, and use of chair/chair egress position. The patient ultimately should sit on the side of the bed. Careful planning is required to monitor patient physiological adjustments to position change (Atkins & Kautz, 2015). As the patient tolerates these activities, he or she is ready to get out of bed to a chair and begin progressive ambulation (Micheletti, 2014).

Progressive ambulation is achievable, but the nurse must coordinate this activity. Thorough patient assessment and scheduling of care activities are necessary. Activity should be planned for periods when the patient is unsedated, free from pain, and hemodynamically stable. Scheduling should be done when other therapies, such as procedures, testing, dialysis, and ventilator weaning, are not being performed. Appropriate safety equipment and staff to participate in activities are essential. Collaboration with other disciplines is indispensable; nursing assistants, as well as physical, occupational, and respiratory therapists, will need to be involved. The physician should be asked to write appropriate activity progression orders (Micheletti, 2014). Using progressive mobility protocols and incorporating all disciplines in daily planning sessions are valuable tools to coordinate collaboration between physicians and staff. Progressive mobility protocols provide organization and define goals for daily patient mobility planning (Atkins & Kautz, 2015).

Contraindications to Exercise

The American College of Sports Medicine (2014) established contraindications to exercise, to include a coexisting diagnosis of uncontrolled diabetes, critical aortic stenosis, acute systemic illness or fever, unstable angina, uncompensated heart failure, acute pericarditis or myocarditis, recent embolism, thrombophlebitis, orthopedic limitations, or metabolic disorders such as hyper/hypokalemia, hypovolemia, or acute thyroiditis. Vital sign exclusions are tachycardia (>120 beats per minute [BPM]), systolic blood pressure (BP) greater than 180 mm Hg, diastolic BP greater than 110 mm Hg, and symptomatic orthostatic hypotension greater than 20 mm Hg drop. Telemetry exclusions include uncontrolled atrial or ventricular tachycardia, third-degree atrioventricular block without pacemaker, and ST depression or elevation greater than 2 mm.

Inpatient end points for exercise include drastic BP changes (diastolic BP >110 mm Hg), orthostatic BP drop greater than 10 mm Hg, substantial ventricular or atrial dysrhythmia, and second--or third-degree heart block. Angina, marked dyspnea, or ischemic electrocardiography changes are critical end points for exercise. In addition, nausea, dizziness, lethargy, and overwhelming fatigue should be considered end points (ACSM, 2014).

Goals of Early Ambulation

Cardiac rehabilitation is defined by the World Health Organization as "the sum of activities required to favorably influence both the subjective cause of the disease and the physical, mental and social conditions of the patient, allowing patients to preserve or reassume their role in the community as soon as possible" (de Macedo et al., 2011, p. 250). Cardiac rehabilitation is divided into three stages. Phase I involves inpatient ambulation with the goal of reducing complications of immobility. An inpatient cardiac rehabilitation service comprised of nurses, exercise physiologists, and physical therapists is instrumental in providing quality ambulation therapies, as well as medical observations of the critically ill patient and appropriate progressive ambulation. In addition, important risk factor reduction and lifestyle modification education is begun by the Phase I cardiac rehabilitation team. Phase II is a telemetry monitored, medically supervised outpatient program lasting 3-6 months, with goals of improved exercise tolerance, risk factor reduction, and reduced mortality. Phase III involves maintenance health promotion that incorporates lifetime exercise and risk factor reduction practices. This phase may or may not be medically supervised (Singh & Schocken, 2015). Successful progression of these phases begins with early progressive mobility in the hospital setting.

As the patient tolerates, activity levels should increase. The expertise of the inpatient cardiac rehabilitation team is vital at this point. The ACSM (2014) recommended workload should be based on the FITT protocol: frequency, intensity, time, and type of activity. Exercise should be performed two to four times daily in the early mobilization phase for the first 3 days in the hospital. Intensity should be established by heart rate (<120 BPM or resting +20 BPM following MI, resting +30 BPM for postoperative patients). Patients can be asked to describe their level of perceived exertion based on the BORG Rate of Perceived Exertion (RPE) scale, range 6-20. RPE should be less than 14, optimally 11-13. Patient can exercise safely as tolerated if nonsymptomatic. Duration should be 3-5 minutes, with rest periods lasting 1-2 minutes between sessions. Exercise should be increased gradually each day.

This approach needs to be taught in the hospital to help the patient establish a pattern at home. Based on in-hospital ability, a home exercise prescription should be planned carefully and explained to the patient so the patient can continue progressive activity after discharge. Teaching should include end points to exercise and notification of physician of adverse events. Review of air quality and appropriate climate restrictions for outdoor activity also is advised (ACSM, 2014).

The goal of progressive ambulation and Phase I cardiac rehabilitation is to enable the patient to reach the next level of activity as an outpatient. Some patients are transferred to skilled nursing facilities to receive physical therapy services to regain lost strength and physical capacities; however, most go home. To rebuild appropriate cardiopulmonary and musculoskeletal strength at home, they need regular aerobic exercise. Patients should be instructed to continue exercising on their own by walking, increasing duration daily. When 10-15 minutes are tolerated, intensity can be increased. This activity should be encouraged until the patient is able to attend an outpatient cardiac rehabilitation program (ACSM, 2014).

In addition to providing progressive ambulation, the Phase I cardiac rehabilitation team educates patients on important risk factor modification and daily routines that remain within the limits of the cardiovascular diagnosis. Preparations for home care are essential to avoid complications and promote healthy recovery (ACSM, 2014). The American Heart Association and the American College of Cardiology have established evidence-based guidelines to decrease the risk of repeated cardiac events (Eckel et al., 2014) . Identifying the patient's risk profile involves (a) detecting treatment and follow-up adherence issues after discharge, (b) educating patients about prescribed medications and the importance of adherence to the medication regimen, and (c) supporting patients in forming goals for lifestyle changes (e.g., smoking cessation). These activities, along with referrals for outpatient cardiac rehabilitation, are performed by the Phase I cardiac rehabilitation team (Singh & Schocken, 2015) .

Outpatient cardiac rehabilitation currently is underutilized. According to de Macedo and colleagues (2011), less than 25% of patients appropriate for outpatient cardiac rehabilitation participate in these programs. Among open-heart surgical patients, this number is 25%-50%. Those who do participate in outpatient cardiac rehabilitation programs often do not maintain consistent exercise upon graduation from the program. An estimated 25%-50% stop exercising 6 months after their event, and 90% stop after 1 year. Lawler, Filion, and Eisenberg (2011) noted, "... better implementation of exercise-based cardiac rehab resources could prove a powerful tool for reducing morbidity, mortality and potentially healthcare costs after MI" (p. 580).

Seizing each patient encounter as an opportunity to provide patient teaching about risk factor modifications is vital. The nurse should collaborate with the physician to ensure appropriate referrals are sent to an outpatient cardiac rehabilitation center convenient for the patient. Ideally, this information should be included in discharge teaching. Registered nurse case managers and Phase I cardiac rehabilitation nurses are essential to ensure this occurs (Arena et al., 2012).

Coordination of outpatient cardiac rehabilitation services depends on home health and community nurses. The home health nurse should monitor the patient to assess readiness for discharge from home health services and progress to the next level of care in cardiac rehabilitation. The home health nurse also should ensure services are scheduled when the patient is discharged from home health (Arena et al., 2012). The community nurse in the physician's office should confirm referrals and orders have been made to an appropriate outpatient cardiac rehabilitation facility. He or she also should provide education on program benefits and the importance of lifestyle modifications, which includes cardiac rehabilitation services.


Nurses working in coronary intensive care and step-down units can implement early ambulation to prevent hospital-acquired immobility complications and ensure patients are walking as soon as is safe after a cardiac event or surgery. A Phase I inpatient cardiac rehabilitation program that includes education on exercise benefits and individualized patient goals is essential for developing long-lasting exercise habits. An equally important service is to provide extensive home care education for risk factor modification. Progressive exercise in the hospital setting helps to reduce patient complications and dispel patient fear of activity. Starting good exercise habits in the hospital can be the beginning of new life style modifications that include a regular exercise routine. The education provided by the inpatient team can increase patients' confidence, empower them with the knowledge to reduce risk factors, and improve adherence to a self-care regimen to prevent recurrence of cardiac events (Singh & Schocken, 2015).


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Joann H. Rion, BSN, RN, is Cardiac Rehabilitation Case Manager, Cone Health, Greensboro, NC.

Donald D. Kautz, PhD, RN, CRRN, CNE, ACNS-BC, is Associate Professor of Nursing, The University of North Carolina at Greensboro, NC.

Acknowledgment: The authors gratefully acknowledge the vision, inspiration, and editorial assistance of the late Elizabeth Tornquist, MA, RN, FAAN.
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Title Annotation:Evidence-Based Practice
Author:Rion, Joann H.; Kautz, Donald D.
Publication:MedSurg Nursing
Article Type:Report
Date:May 1, 2016
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