An outline of the evidence for cardiac rehabilitation (CR) and its four phases, describing innovations in Cornwall. It discusses how CR was developed in Cornwall using audit and local research, strengthening the interface of primary and secondary care to provide a seamless service for patients who experience a myocardial infarction
Keywords: Cardiac care, Cardiac rehabilitation, Service development
Authors Jennifer Wingham, RGN, BNS, is research nurse; Catherine Proctor, RGN, is cardiac rehabilitation liaison nurse; both at Royal Cornwall Hospital, Truro; Hasnain Dalal, MD, FRCGP, is a GP at Lower Lemon Street Surgery, Truro.
Abstract Wingham, J. et al (2007) Improving provision of cardiac rehabilitation services.
Coronary heart disease is a leading cause of chronic illness. In the UK there has been significant investment in cardiac interventions but little in enabling patients to improve or manage their condition. This article outlines the evidence for cardiac rehabilitation (CR) and its four phases, and describes innovations in Cornwall. It discusses how CR was developed in Cornwall using audit and local research, strengthening the interface of primary and secondary care to provide a seamless service for patients who experience a myocardial infarction. Future development needs are identified at local and national level and the aims of a multi-agency national campaign for cardiac rehabilitation are presented.
Coronary heart disease (CHD) is a major cause of death and disability throughout the developed world and a challenge for health service provision (Yusuf et al, 2001). Cardiac rehabilitation (CR) is an evidence-based intervention that aims to optimise patients’ functioning, enhance quality of life and minimise the risk of recurrent cardiac events (Scottish Intercollegiate Guidelines Network, 2002). The World Health Organization (1993) defines CR as: ‘…the sum of the activities required to influence favourably the underlying cause of disease, as well as to ensure the patient’s best possible physical, mental and social conditions so that they may by their own efforts, preserve, or resume when lost, as normal a place as possible in the life of the community. Rehabilitation cannot be regarded as an isolated form of therapy, but must be integrated with the whole treatment, of which it forms only a facet.’ The intervention therefore involves patients and healthcare professionals working in partnership to maximise individuals’ physical, mental and social potential.
Systematic reviews have confirmed the beneficial effects of CR (Jolly et al, 2006; Rees et al, 2004; Jolliffe et al, 2000). It is an inexpensive treatment that saves lives, reduces disability and improves health-related quality of life (British Heart Foundation, 2007a). The National Service Framework for Coronary Heart Disease (Department of Health, 2000) recommended that CR be made available to all patients with CHD, not just those who have had an MI. Despite this, provision and uptake of CR remains poor (Bethel et al, 2001; BHF, 2007a).
The Scottish Intercollegiate Guidelines Network (2002) identified four phases of CR. Phase 1 occurs during hospital admission with a change in a patient’s cardiac condition and includes risk assessment, education and advice, reassurance and discharge planning. Phase 2 is the early discharge period when patients may feel isolated and insecure. Usually they are supported by telephone contact but there may also be home visiting. Phase 3 is structured CR with advice on disease management, lifestyle, medication and an exercise programme. Phase 4 is long-term maintenance through exercise or physical activity and a healthy lifestyle. This may also include a long-term support group or gym membership. There are many phase 4 groups around the UK, supported by organisations such as the BHF and facilitated by a British Association for Cardiac Rehabilitation (BACR) trained instructor. Secondary prevention measures including prophylactic medication delivered through chronic disease management clinics in primary care should be an integral part of phase 4 CR.
In the UK there are two main structured programmes for CR: home-based or group-based, usually in a hospital setting. Cornwall’s six-week home-based programme uses the Heart Manual – a book and two tapes or CDs that provide information and advice on CR including symptom changes, lifestyle advice, exercise, medication and psychological care (www.theheartmanual.com; Lewin, 1992). A trained nurse facilitator supports its use through home visits and telephone contact. The Heart Manual is used during phases 2 and 3. The group-based programme consists of the above information presented in weekly outpatient classes, with exercise as a core component facilitated by a team of CR professionals.
The BACR (2007) standards and core components for CR (2007) recommend that the core team includes a cardiac specialist nurse, physiotherapist, dietitian, administrator and a designated clinical lead (a cardiologist or GP specialist in cardiology). Clearly nurses have a key role in developing and delivering services through all four phases of CR. In Cornwall, a nurse coordinator leads each CR team but they lack a dietitian or consultant cardiologist. There is a CR team based at the Royal Cornwall Hospital (Treliske) funded by the Royal Cornwall Hospitals NHS Trust and three community teams funded by the Cornwall and Isles of Scilly PCT. One of these provides phase 1 CR at the West Cornwall Hospital.
Cardiac rehabilitation development in Cornwall
A physiotherapist and a cardiologist set up Cornwall’s rehabilitation service in the early 1980s at the Royal Cornwall Hospital in Truro. From 1985 onwards it was coordinated by a CR nurse. The programme was hospital-based with funding for fewer than half of patients recovering from MI. There was no formal link between primary and secondary care, and patients discharged after MI had no systematic or structured long-term follow-up.
In 1998, a conference organised by the then Cornwall and Isles of Scilly Health Authority identified several areas for improvement in local CR services. It recommended that coordination of services between primary and secondary care be improved and a community-based rehabilitation service be set up for patients who had difficulties accessing hospital facilities. Geography was one significant consideration – Cornwall is predominately rural and stretches some 70 miles from Lands End to its border with Devon. Provision of CR was patchy and there was no formal link between secondary and primary care, so patients discharged after MI did not have systematic long-term follow-up.
An innovative scheme offering CR to patients who survive a heart attack in the Carrick district of Cornwall won funding from the BHF after a pilot project based in a Truro surgery showed positive outcomes and was highlighted in the NSF for CHD (DH, 2000) as an example of good practice.
The service was established in 1999 and funding was granted for two years to establish a seamless CR service that incorporated nurse-led secondary prevention clinics in primary care. Following the success of this scheme, the former Carrick Primary Care Group and the then Central Cornwall PCT agreed to provide long-term funding for a CR liaison nurse to work with the hospital-based CR team at the Royal Cornwall Hospital.
The PCT also provided chronic disease management funding for practice nurses to run CHD clinics where patients discharged from hospital after MI would be seen, offering lifestyle advice and monitoring. Payments for these clinics are now included in the new GP contract as part of the Quality and Outcomes Framework (QOF).
The service is strengthened by excellent links between primary and secondary care and further enhanced by six-monthly staff training/update sessions organised by the CR liaison nurse, with funding from pharmaceutical companies. Fourteen of these sessions have been held since 1999, with more than 30 attending each one. Initially, participants were mainly lead CHD practice nurses from the PCT, but they now include many members of the multidisciplinary team such as CR nurses from the acute trust, physiotherapists, occupational therapists, psychologists and medical staff. An audit on post-MI patients from Carrick demonstrated that it was possible to achieve NSF milestones for CR and secondary prevention when service provision is integrated between secondary and primary care (Dalal and Evans, 2003).
- Phase 1
All patients admitted to the Royal Cornwall Hospital who have had an MI are identified via a daily printout of cardiac biomarkers (troponins), and have face-to-face contact with a CR nurse or the CR liaison nurse before discharge.
Clinical, psychological, social and vocational needs are assessed and individual care is planned accordingly. Family members can be involved if the patient wishes. Appropriate referral is made to other services such as smoking cessation, the psychological team or occupational therapy for a return-to-work assessment, or other specialist nurses. Patients are assessed for their suitability for an exercise programme, which either follows the Heart Manual or the group-based programme. West and Central Cornwall has Cardiac Professionals Together Utilising Rehabilitation Services for the Elderly (CAPTURE), a programme funded by the BHF and the Big Lottery Fund, led by a physiotherapist and aimed at older people with multiple co-morbidities. This service has yet to be evaluated.
- Phase 2
Within the first few days of discharge, all suitable patients are followed up by telephone. All those using the Heart Manual are followed up at home by visits or telephone.
The CR team is notified by a tertiary hospital of all patients who have had cardiac revascularisation surgery and these receive similar follow-up. Once wounds have healed, usually 6–12 weeks after surgery, patients are assessed for referral to a group-based exercise programme.
The community CR nurses and the CR liaison nurse refer both groups of patients to the CHD practice nurses for long-term secondary prevention follow-up. Where appropriate, patients can be referred back to the CR team, for example if intervention from the psychologist is required.
- Phase 3
All patients attending the group-based programme are contacted by the CR nurses and offered a choice of venue. High-risk patients generally attend a programme for eight weeks. Phase 3 CR classes are held across Cornwall, at the Royal Cornwall Hospital and in community-based settings such as community hospitals and leisure centres. Other venues are being explored to provide care near to patients’ homes and in a ‘normal’ environment, to promote the concept that CR is ongoing after health service provision.
Group sessions include an exercise programme meeting BACR standards, while the flexible, menu-based education programme can be tailored to individual needs. Patients are advised on reducing risk factors and given education on a range of topics including medication, weight reduction, smoking cessation and managing stress.
- Phase 4
Some patients have formed their own support groups to carry on the social support and exercise component. The CR teams provide advice where requested but these groups belong to the members. They are affiliated to the BHF.
Cardiac rehabilitation research in Cornwall
When a patient attending the GP surgery did not want to attend a group-based programme his GP and practice nurse (now CR liaison nurse) looked for an alternative to group-based CR. This led to another service innovation offering a choice of hospital-based or home-based CR to patients admitted to the Royal Cornwall Hospital, initially to the Carrick area and later to the West of Cornwall as well. These developments occurred when there was national uncertainty about the efficacy of home-based CR. A pragmatic randomised controlled trial with patient preference arms (CHARMS – Cornwall Heart Attack Rehabilitation Management Study) was carried out to compare the clinical outcomes of quality of life, depression and anxiety, exercise tolerance and lipid profile with each form of CR after an MI. The cost-effectiveness of home and hospital-based CR was also assessed. The study showed that home-based CR was as clinically effective as hospital-based CR (Dalal et al, 2007). Both methods of CR were also shown to be cost-effective (Taylor, 2007).
Nested within the study was a qualitative study to explore patients’ experience of MI and to identify the factors that influence their decision to opt for hospital- or home-based CR (Wingham, 2006). Seventeen participants were interviewed before their rehabilitation programme. Common to both groups was shock and disbelief, leading to a loss of confidence. They expressed a strong desire to make lifestyle changes and looked for advice, guidance and support from experts. The hospital-based group tended to emphasise the importance of supervision during exercise, they needed the camaraderie of a group, were willing to make transport arrangements and believed they lacked self-discipline. By contrast, the home-based group believed that their CR should fit in with their lives rather than their lives fitting in with CR and were self-disciplined. They disliked groups and expressed practical concerns. Some of them said that if the Heart Manual had not been available they would not have participated in CR.
It was concluded from the CHARMS trial and the qualitative study that both hospital and home-based CR services should be provided widely in the UK in order to help address the patchy and sub-optimal uptake by offering a choice of CR methods to patients recovering from MI.
- Audit and workload
Cornwall participates in a BHF-funded national CR audit led by Professor Bob Lewin (Minimum National Dataset for Cardiac Rehabilitation Project, 2007).
A recent audit demonstrates that during March-June 2007, 512 patients were admitted to the Royal Cornwall Hospital with symptoms of an MI. The diagnosis was confirmed in 399 of these. Some 365 patients survived and were assessed by the CR nurses. Of these, 297 (81%) were seen face-to-face and a further 68 (19%) were assessed through a review of their hospital records. In total, 207 were referred for phase 2 CR around Cornwall. A further 11 were referred to CAPTURE Cornwall, 55 were referred to the primary care-based CHD nurses for follow-up and 11 to the community heart failure nurses.
Audit by the CRLN indicates that for 2005-2006, 21.5% completed the home-based programme and 23% completed the group-based programme. Some 55.5% were not suitable for a formal exercise programme due to serious co-morbidity, for example dementia, arthritis, stroke or respiratory illness. Future audit plans include the collection from all the CR teams of data regarding patient participation in either group- or home-based programmes across Cornwall.
Ongoing internal audit demonstrates that the Royal Cornwall Hospital CR team has seen a significant increase in workload in meeting the needs of post-MI and surgical patients. The CR liaison nurse audit indicates her workload has almost doubled without further resources.
Table 1. Increase in cardiac workload in the Carrick area
|2006||% increase in workload|
|Coronary artery bypass graft||55||81||32|
|Percutaneous coronary intervention||0||80||N/A|
Funding was not available in 2000 to provide CR for patients with a negative troponin test undergoing percutaneous intervention, for example in chronic stable angina. These patients are now seen thanks to improvements in the efficiency of service provision.
Discussion and future developments
There is clear evidence that CR provides benefits in addition to the improvements seen with secondary prevention alone (Jolly et al, 2006).
Systematic review has also demonstrated that CR is cost-effective (Papadakis et al, 2005). Currently the NHS is facing financial challenges and CR is not yet a priority, despite the investment in cardiac technologies. Investment in CR would seem appropriate, however, given the evidence of its efficacy and especially as it enables individuals to regain confidence and manage their own health. This is demonstrated by a woman who described CR as: ‘Getting myself well, I suppose, and sorting your life out. Changing your way of living if you want to go on living’ (Wingham, 2006).
Despite the successes in Cornwall the service remains patchy across the county and there are areas that are unable to offer a choice of CR. The service focuses on those patients who have had an MI. Although it meets the requirements of the recent NICE guidance on MI patients (NICE, 2007), in which CR featured prominently, it fails to meet the SIGN, BACR and NSF targets for all patients with CHD. These include those admitted to hospital with heart failure, acute coronary syndrome and after percutaneous intervention with angioplasty and/or stenting.
A newly launched BHF national campaign for CR (2007a; 2007b) observes that the outlook for cardiac rehabilitation is less secure now than it was in 2006 despite support from the government’s national director for heart disease and stroke. Some programmes have closed and others are under threat. CR is mainly organised by nurses and physiotherapists and has lacked a powerful champion. The involvement of cardiologists and GPs is essential when representations are made to strategic NHS planning groups and charitable organisations that allocate funding. Successes in Cornwall have been instrumental in securing further grants from the BHF and the Big Lottery Fund to improve the care of patients with heart failure in the community (the Heart Failure CoNNeCT project) and for providing CR to patients over 75 who are not able to access the CR service (the CAPTURE Cornwall project).
The service improvements presented in this article have resulted largely from health professionals, including nurses, working together. Two GPs promote the needs of cardiac patients at PCT level and, together with nurse representation, drive the service forward. Many of the developments in Cornwall would not be possible without the support of the GPs but - as in many parts of the UK - would benefit from greater involvement from cardiologists. The BHF national campaign for CR, ‘Cardiac Rehabilitation…Recovery or Bypass?’, in alliance with leading organisations and charities, has five aims:
• That every heart patient who is suitable and wishes to take part is offered a rehabilitation programme;
• That patients should be offered alternative methods, such as home-based rehabilitation, if they prefer not to take part in a group programme or attend hospital as an outpatient;
• That efforts be made to ensure that rehabilitation programmes meet the needs of under-represented groups, particularly black and minority ethnic groups and women;
• That each programme should meet the minimum standards set out by the British Association for Cardiac Rehabilitation;
• That their compliance with these standards be monitored though the National Audit of Cardiac Rehabilitation.
Significantly, patient groups are part of the campaign and a large contingent attended the 7th York Cardiac Care Conference (2007). Their voice is very important and will continue to be a key part of improving cardiac services at a local and national level.
CR nurses and professionals need to learn the skills of business planning, use the BHF campaign and patient voices to promote their services and demand evidence-based cardiac rehabilitation as recommended in the NSF (DH, 2000). This will encourage PCTs and acute trusts to work together to provide improved services to support patients living with and managing a chronic condition.
CR is a fundamental part of recovery and management in CHD, and providing a choice of methods for its delivery is important to improve poor uptake. Cornwall has made many improvements in CR through commitment and joint working between health professionals across primary and secondary care. While there have been significant successes, with confirmatory evidence from audit and research findings, there is still a need for improvement to meet national standards.
We would like to acknowledge Alison Brown, cardiac rehabilitation coordinator, Royal Cornwall Hospital, for assistance with providing the audit statistics; the CR teams across Cornwall; patients who have taken part in the research and provided our evidence; and Dr Tony Mourant, a recently retired consultant cardiologist, for commenting on a draft of this paper.
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