Cardiac rehabilitation, a comprehensive program to get patients healthy again after heart attack, cardiac surgery or other cardiac events, has been shown to save lives. But what if patients waiting for non-emergency heart surgery could start improving their health before their procedure? Could that make their recovery easier and improve their outcomes after surgery?
In December 2016, such a “prehabilitation” program—Cardiac PreHab for short—was rolled out to all patients at the Heart Institute waiting for coronary artery bypass surgery or heart valve replacement or repair.
“Rather than letting the waiting period for a procedure be one of inactivity and anxiety, PreHab can use that time to help patients become as ready as possible for their procedure,” said Heather Sherrard, Executive Vice President of Clinical Operations and Chief Nursing Officer at the Heart Institute. “They may need to quit smoking, their diabetes may need to be better managed, they may be able to improve their diet or level of exercise. The PreHab program can help with these issues to get these patients as fit as they can be.”
Portions of the new program have been in place for a while, explained Jane Brownrigg, Clinical Manager of Cardiac Rehabilitation at the Heart Institute. Patients waiting for outpatient procedures who come in for pre-admission appointments have long been connected with services such as smoking cessation, physiotherapy or social work on an ad-hoc basis.
The PreHab program aims to standardize these assessments and referrals and make them as comprehensive as possible for all patients waiting for outpatient surgery. Every patient placed on such a waiting list has their name passed to the PreHab nurse, who calls the patients to discuss a list of issues, including medications, diabetes, smoking, nutrition, physical activity, mental health and symptom management.
Patients have a lot of misconceptions about what they should be doing before surgery, explained Brownrigg. “We talk to patients waiting for surgery who say ‘My doctor told me to take it easy,’ and they’ve interpreted that as ‘Just sit on the couch’.” This lead to a loss of conditioning, which slows recovery. Many think they should go on a diet, she continued, which can actually cause muscle loss—an unwanted side effect before any procedure.
The PreHab nurses address these issues, using the cardiac rehab model. Medications are optimized based on clinical guidelines. All patients are screened for diabetes and referred to smoking cessation, if needed. They also receive referrals to a dietitian, social worker, vocational counsellor, psychologist or other health professional as deemed necessary.
In the second stage of the process, PreHab participants and their caregivers who will be helping them after surgery are invited to an in-person workshop that includes demonstrations of many of the skills described in the initial phone call, from blood sugar monitoring to safe movement after surgery. Patients also have an opportunity to ask any questions that weren’t addressed.
The workshop even covers logistical issues, like who will drive the patient home after they’re cleared to leave the hospital and how the home environment can be temporarily modified to make it easier to move around during recovery. This makes it possible for patients to be discharged as soon as possible. “No one wants to stay in hospital longer than they have to,” commented Brownrigg.
Three workshops have been held since the program’s December launch. “We’ve been struck by the very high rating of the workshop when we did the evaluations,” she added.
As patients complete PreHab, data will be gathered to evaluate the program. “Is it improving patient function, quality of life and recovery after surgery? Is the recovery phase shorter? Are things like infection rates and blood-sugar control improved? These are some of the clinical factors we want to look at,” said Brownrigg.
“And from a ‘self-centred’ perspective,” she added, “we want to see if patients who come to PreHab are more likely to come to rehab because they’ve been oriented to us. We enjoy a very high rate of enrolment for rehab compared to other centres across the country, but we still only get a little above half of all eligible patients to enroll. We’d like to increase that number because we know that rehab reduces morbidity and mortality rates,” she concluded.