How to Start Rehabilitation Setting for Cardiac Cases

Deddy Tedjasukmana

Department of Physical Medicine and Rehabilitation, Cipto Mangunkusumo National General Hospital,

University of Indonesia, Jakarta, Indonesia

Deddytedjasukmana60@gmail.com

Keywords: Cardiac Rehabilitation Setting, Cardiac Rehabilitation

Abstract: Cardiac rehabilitation is a multidisciplinary program of exercise program, education, risk factor

modification, and psychosocial counseling that reduces mortality and hospital stay, improves quality of life

in patients with heart disease. Cardiac rehabilitation program is important for management of heart disease.

The programs demands a multidisciplinary approach based on the premise that decisions on the goals of

treatment should be made by the insight of several professions, therefore the practitioner requirements for

cardiac rehabilitation should have competencies across various disciplines such as medicine, nursing,

exercise physiology, physical and occupational therapy, psychology, sociology, pharmacology, and

education. Standard facilities also required by hospitals to provide an ideal setting of cardiac rehabilitation.

1 INTRODUCTION

Cardiac rehabilitation is a multidisciplinary program

of exercise program, education, risk factor

modification, and psychosocial counseling resulted

in reduces mortality and hospital stay, improves

quality of life in patients with heart disease. Cardiac

rehabilitation is a coordinated program, multifaceted

interventions designed to optimize a cardiac patient's

physical, psychological, and social functioning, in

addition to stabilizing, slowing, or even reversing

the progression of the underlying atherosclerotic

processes, thereby reducing morbidity and mortality.

The purposes of cardiac rehabilitation is to improve

regular physical activities and to control the

modifiable risk factors. Another purposes are

education that emphasize the importance of the

healthy lifestyle and help manage psychosocial

problems. Centre for Medicare and Medicaid

Services (CMS) recommends cardiac rehabilitation

interventions as a multidisciplinary program that not

only involves exercise therapy in cardiac patients but

also involves counseling and education for patients

who are already in stable condition, thus improves

the transition from the hospital to the community. It

believes that cardiac rehabilitation improves exercise

tolerance, reduces symptoms of heart disease, lipid

levels, frequency of smoking, stress levels and

increases adherence to treatment and the patient’s

psychosocial life. This is in turns lead to increase

independence and improvement in general sense of

wellbeing (Mampuya, 2012).

Cardiac rehabilitation program is an important

part of the management of heart disease. The

concept of cardiac rehabilitation initially focused on

exercise therapy, later developed into a

comprehensive secondary prevention strategy in

dealing with risk factors, nutrition, psychological

and social factors that can affect patient’s recovery

process. Cardiac rehabilitation which acts as a

secondary prevention relies on early detection and

application of several interventions (education,

counseling and behavior) to encourage lifestyle

changes and modify the risk factors. Clinical

research has shown that early detection and

modification of risk factors can reduce the incidence

of heart disease (Piepoli et al, 2010).

2 DISCUSSION

2.1 Phase of Cardiac Rehabilitation

In its implementation, the cardiac rehabilitation

program is classified into several phases: Phase I is

an immediate effort while the patient is still in the

treatment period, the main objective of this phase is

to reduce or eliminate the adverse effects of

Tedjasukmana, D.

How to Start Rehabilitation Setting for Cardiac Cases.

DOI: 10.5220/0009062000440047

In Proceedings of the 11th National Congress and the 18th Annual Scientiﬁc Meeting of Indonesian Physical Medicine and Rehabilitation Association (KONAS XI and PIT XVIII PERDOSRI

2019), pages 44-47

ISBN: 978-989-758-409-1

'deconditioning' due to prolonged bed rest, early

education and so that the patient is able to do their

daily activities independently and safely. Phase II,

which is carried out as soon as the patient is

discharged, is an intervention program to restore

patient function to the optimum, immediately

controlling for risk factors, education and additional

counseling regarding a healthy lifestyle. Phase III

are maintenance phases, where the patient is

expected to be able to carry out a rehabilitation

program independently, safely, and maintain a

healthy lifestyle forever, assisted or together with

the family and surrounding community. Since 1994,

the American Heart Association (AHA) has declared

that cardiac rehabilitation is not limited to physical

exercise programs, but must include

multidisciplinary efforts aimed at reducing or

controlling modifiable risk factors (Price et al, 2016).

2.2 Cardiac Rehabilitation Setting

One of the fundamental component of rehabilitation

is educating the patients and their families. The

ability of each practitioner to educate the disease

situation will affect their attitudes and promote

changes in lifestyle which is the key of success for

rehabilitation program. Where possible, all cardiac

rehabilitation practitioner should be able to

overcome the cultural and linguistic barrier of the

patient and family.

Cardiac rehabilitation programs

demands a multidisciplinary approach, therefore the

practitioner requirements for cardiac rehabilitation

should have competencies across various disciplines:

medicine, nursing, exercise physiology, physical and

occupational therapy, psychology, sociology,

pharmacology, and education. The interprofessional

approach of the cardiac rehabilitation is based on the

premise that decisions on the goals of treatment

should be made by the insight of several professions

and a common framework. To obtain insight into an

interprofessional approach the practitioner should

have participated in the patients services offered by

other proffesions and have regularly been updated

within the individual competence through staff

meetings and interproffesional conferences.

2.3 Cardiac Rehabilitation Program

Cardiac rehabilitation encompass baseline patient

assessments, nutritional, psychosocial and physical

activity counseling, risk factor management (lipids,

hypertension, weight, diabetes, and smoking) and

exercise training. Practitioner must be able to

perform assessments, educate and provide effective

interventions in the following fields:

cardiopulmonary and musculoskeletal anatomy,

physiology, and pathology; cardiovascular disease

risk factors; nutrition; physical functioning and

exercise therapy; psychosocial; health behavior;

vocational; and pharmacy (Schou and Zwister, 2019).

All professions must be given the opportunity for

further education and continous update within

science (Schou and Zwister, 2019).

Phase I (inpatients) program consists of early

mobilization, identification and education of

cardiovascular risk factors, medication instruction,

and discharge planning. The practitioner must

conduct baseline cardiovascular, pulmonary,

musculoskeletal, and psychosocial assessments.

Based on the data collected, an individualized

program of physical activity and education could be

determined. Multidisciplinary team includes

certified nurse specialist; registered dieticians;

physical and occupational therapists, exercise

specialists and physiologists; pharmacists; social

workers; and discharge planners. The staffs should

know their competency relative to clinical

indications and contraindications for cardiac

rehabilitation. Staff who is in charge of early

mobilization and physical activity of patients must

be familiar with the adverse responses which require

discontinuation of the activity. For large patient

populations, the program may have a Cardiac

Rehabilitation Coordinator or Cardiac Rehabilitation

Educator (usually a nurse) who coordinates the

above team of providers and responsible for special

patient populations (e.g., higher-risk patients).

Phase II (outpatients) program requires staff who

have the following competencies: cardiovascular,

pulmonary, and musculoskeletal assessment; risk

factor management, pyschosocial assessment and

intervention; behavioural counselling,

electrocardiogram (ECG) interpretation; medical

emergency management; and exercise therapy

theory and practice. The staff must be able to

perform individual patient assessments, help patients

to set achievable goals and evaluate progress toward

goals. Patient monitoring in phase II include rating

of perceived exertion (RPE), recording of heart rate,

blood pressure, respiratory rate and symptoms pre

and post activity. For home-based programs, staff

(usually nurse) interact with patients via telephone

and do periodic visits. The staff should have

competency in the areas of exercise assessment,

prescription, and evaluation. One competent

practitioner supervise a low intensity physical

activity program for groups of less than 10 patients.

For groups of 10-15 patients, or for a moderate

How to Start Rehabilitation Setting for Cardiac Cases

intensity physical activity program, a second person

needed with current cardiopulmonary resuscitation

accreditation. Patient with conditions that need

specific medical assessment prior to participating in

the physical activity program include those with

unstable angina, uncontrolled hypertension, severe

aortic stenosis or uncontrolled diabetes, complicated

acute myocardial infarction, untreated heart failure

or cardiomyopathy and those with symptoms such as

shortness of breath on low exertion or a resting heart

rate over 100 beats/minute. It is highly

recommended that cardiac rehabilitation staff obtain

certification(s) in their respective fields. In phase 3,

the practitioner will prescribe specific exercises to

help improve endurance level and activity tolerance.

Typical exercises performed during phase 3 are

treadmill walking, rowing, biking, upper body

ergometer, upper and lower body strength exercises

and flexibility exercises. Phase 3 often occurs in a

group exercise setting. This helps patient to socialize

with others and keep the patient feel motivated

during phase 3 cardiac rehabilitation (Sears, 2019).

2.4 Standard Facilities

Standard facilities required by hospitals to provide

services as well as possible for the patient. The main

electricity source of the building must be use

electricity from the State Electricity Company.

Buildings, rooms or special equipment must have a

standby power supply whose power can meet

continuity of service with these requirements. Air

conditioner is needed for patients to feel comfortable

in the rehabilitation building. The manager of the

medical rehabilitation building must consider

temperature and humidity, including consideration

of the room function, number of users, location,

room volume, type of equipment, the use of building

materials, ease of maintenance and care, and

principles of energy saving and environmental

sustainability. Building should be equipped with

audio-visual facilities and sound system (Price,

2016).

Based on Cardiac Rehabilitation Staffing by

Lawson, cardiac rehabilitation programs have an

ideal setting of place as follow :

 Reception area: its most important function is

receiving patients and coordinating each

patient’s programme. The 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.

 Toilet and bathroom: Located near the waiting

room, with facilities for both men and women.



Consultation rooms: the are includes a computer,

telephone, examination table and

sphygmomanometer.

 Weighing: The scale is electronic and is

calibrated regularly. It can weigh patients up to

200 kg

 Testing room: A consultation room has a testing

cycle and examination table to test aerobic

functioning

 Exercise facilities: the facilities is equip with

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

 Kitchen: The Unit has a kitchen in which the

dietitian and the patients and their families cook



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

 Group room: Room where patients is being

educated, this room has a table, chairs, computer

with a projector, whiteboard, screen, overhead

projector and television with videocassette player.

 Workplaces: The workplaces that can

accommodate any staff member

 Storage depot

Physical activity can trigger adverse cardiac

events. Cardiac Rehabilitation Unit should give high

priority for patient safety. The program requires two

staff members that have been trained in basic cardiac

resuscitation to be present whenever patients are in

the exercise rooms. The equipment required for

safety are (Schou and Zwister, 2019):

 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



Pharmaceuticals: In accordance with the

guidelines of the Copenhagen Hospital

Corporation, pharmaceuticals are kept in a

locked medicine cabinet. There is medicine to

treat all types of acute illness, such as cardiac

arrest, heart and lung disease and acute diabetic

conditions.



Acute illness: The program should have a

protocol when a emergeny arise related to

congestive heart failure, tachycardia, syncope,

chest pain and other acute illness

KONAS XI and PIT XVIII PERDOSRI 2019 - The 11th National Congress and The 18th Annual Scientiﬁc Meeting of Indonesian Physical

Medicine and Rehabilitation Association

 Cardiac arrest: The following procedure for

cardiac arrest are alarm is sounded, initiaton of

resuscitation and treatment, then transfer patient

to intensive care accompany by the physician

2.5 Barriers of Cardiac Rehabilitation

Participation

Social, psychological, and demographic variables

have an effect on participation in cardiac

rehabilitation. These factors include age, sex, race,

doctor's recommendations, patient's knowledge of

his illness, patients' expectations of cardiac

rehabilitation, feelings of self-efficacy, mood and

self-defense mechanisms (Tedjasukmana and Putra,

2016). All of these studies also showed differences

in participation in cardiac rehabilitation in women,

the elderly and minorities.

Gender differences

could affect participation in cardiac rehabilitation,

women have lower participation than men. Barriers

to women's participation are lack of income sources,

transportation difficulties, and lack of social or

emotional support. Other obstacles to patient

participation are motivation, interest and time.

Although studies show the elderly have a greater

need for cardiac rehabilitation and get good results

with a low rate of undesirable events, the elderly are

more often not referred or do not attend cardiac

rehabilitation. Race and ethnic minorities have high

rates of cardiovascular disease and associated risks,

but low participations in cardiac rehabilitation are

mainly due to lack of access, low referral rates and

insurance protection (Torres, 2017).

3 CONCLUSION

Cardiac rehabilitation program is an important part

of the management of heart disease. Cardiac

rehabilitation which acts as a secondary prevention

relies on early detection and application of several

interventions (education, counseling and behavior)

to encourage lifestyle changes and modify the risk

factors. Clinical research has shown that early

detection and modification of risk factors can reduce

the incidence of heart disease. One of the

fundamental component of rehabilitation is

educating the patients and their families. The

programs demands a multidisciplinary approach

based on the premise that decisions on the goals of

treatment should be made by the insight of several

professions, therefore the practitioner requirements

for cardiac rehabilitation should have competencies

across various disciplines such as medicine, nursing,

exercise physiology, physical and occupational

therapy, psychology, sociology, pharmacology, and

education. To obtain insight into an interprofessional

approach the practitioner should have participated in

the patients services and have regularly been

updated within the individual competence through

staff meetings and interproffesional conferences.

Standard facilities also required by hospitals to set

an ideal setting of cardiac rehabilitation program.

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How to Start Rehabilitation Setting for Cardiac Cases