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Heart to Heart with Cardiac Rehab Nurses

Monday February 23, 2004
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Cardiac rehabilitation nurse is one of the most
sought after positions in nursing today. What is it
about this area that is so enticing?

"I am fortunate to be able to live my passion," says Jodi Boutwell, RN, BSN, of the Cardiovascular Center at St. Joseph Hospital, Nashua, NH. "I work with a dynamic and innovative team of healthcare professionals dedicated to providing exemplary patient care."
Boutwell is a cardiac rehabilitation nurse, one of the most sought after positions in nursing these days. And she is not alone in her enthusiasm for her work. From the nursing perspective, the field is highly desirable because the patients are motivated, the hours are great, and the multidisciplinary team approach allows professional autonomy.
Cardiac rehabilitation is a growing field due to the multiple indications for referral, such as myocardial infarction, stable angina, coronary artery bypass surgery (CABG), valvular replacement, cardiac transplantation, percutaneous transluminal coronary angioplasty (PTCA) with or without stenting, heart failure (CHF), and coronary artery disease (CAD). Cardiac rehab programs provide medical evaluation, supervised exercise, risk factor modification and education, and psychosocial support for these patients.
The cardiac rehab programs generally consist of three phases: in hospital/inpatient, early recovery/immediate outpatient, and late recovery/maintenance. At Baystate Health Systems, Springfield, MA, there are currently 7,000 patients enrolled in
Phase Two, and another 21,000 in Phase Three.
"Our program is called Cardiac Rehab and Wellness, as the focus is on the continuum of care, rather than episodic management of events," says Betty LaRue, RN, MN, director for cardiac and pulmonary services. "Our inpatient practice guidelines automatically trigger a referral to cardiac rehab for appropriate patients." Likewise, other cardiac rehab programs, such as "Living Wellthy" at St. Joseph Hospital, emphasize ongoing attention to maintenance.
Making a Difference One Beat at a Time
The nurse is the ongoing support person for the client, providing education in heart disease and lifestyle changes. Cardiac rehab nurses impact care through their expertise in cardiovascular pathophysiology and assessment, dysrhythmia interpretation, and emergency management of complex clinical situations. They determine whether to call the physician for symptoms or to send the patient directly to the ED. Many have prior experience in inpatient cardiac care, particularly the cardiac intensive care and telemetry units.
Strong teaching and communication skills certainly help the cardiac rehab nurse. And most cardiac rehab nurses are baccalaureate prepared and trained in Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS), and many are certified through the American Nurses Association.
"Our goals are to help people understand their risk factors, symptoms, and appropriate treatment," says Boutwell. "Exercise is a modality to improve functional capacity, quality of life, and mobility for return to work, hobbies, and activities, while also decreasing depression."
Rehab Ins and Outs
The cardiac rehab staff may include cardiologists, RNs, physical therapists, exercise physiologists, nutritionists, pharmacists, and psychiatrists. Elisa Stokowski, MBA, exercise physiologist and manager of Cardiac Rehabilitation and Wellness at Baystate, describes the interdisciplinary approach as a nice mix. "On the nursing side you have that critical thinking piece and on the exercise physiologist side you have the expertise in exercise prescriptions," says Stokowski. "They really rebound ideas off each other well."
The focus of Phase One - inpatient cardiac rehab - is on education and activity progression. Phase Two includes a telemetry-monitored and supervised exercise program, with sessions typically two or three times per week, ranging in duration from six to 15 weeks. The RN most often conducts the initial patient intake evaluation. Risk factors are identified and the nurse, exercise physiologist, and other members of the team develop an individualized care plan/prescription. Issues to be addressed may include weight management, smoking cessation, lipid management, hypertension, and stress reduction.
According to Elizabeth Heiman, RN, MSN, program coordinator, Cardiovascular Health Center, Newton-Wellesley Hospital, the patients have a stress test prior to the exercise portion of the program. "A training heart range is calculated for the patient and we use this, as well as client feedback, to guide exercise," says Heiman.
Boutwell adds, "We find that those who exercise first thing in the morning tend to be more compliant because the only thing they wrestle with is the bed. It energizes them and they feel great."
Cardiac rehab patients typically experience significant anxiety related to the diagnosis, how much they can do, and whether they will have more problems. With cardiac rehab the clients gain the confidence necessary to resume activity without fear of another heart attack. Relaxation tapes and awareness tools may help the patient deal with stress.
Phase Three cardiac rehab is not monitored, nor reimbursed. However, says LaRue, many patients elect to remain with the program as they prefer the medical model versus a gym.
"Cardiac rehab is something you have to stick with, as it takes time for real behavior modification," she says. "Should these programs be reimbursed? Well, the reality is that in the long-term, it's better to keep people healthy than to pay for their bypasses."
With Programs, the Choice Is Yours
The cardiac rehab program at Care New England Wellness Center in Rhode Island is geared to outpatients only. "As an affiliate of the Beth Israel Mind-Body Institute, our program emphasizes a self care model, with independence, exercise, and stress management at home and work, as well as within the program," says Kathleen Congdon, RN, BSN. "Both Phase Two and the Maintenance program are housed in a health club, creating a seamless transition, camaraderie, and connections for those patients who choose to stay on." In fact, Care New England patients receive a three-month membership in the health club as part of the cardiac rehab program.
There is an ongoing demand for more cardiac rehab classes and longer programs, as both clients and healthcare providers become more attuned to its benefits. Many programs have recently expanded their facilities and staff. Baystate offers "Change of Heart," a year-long intense reversal program, where nursing plays a central role in classes that include aerobic exercise, food preparation, Tai Chi, yoga, and group support.
Care New England is participating in the Medicare-sponsored Lifestyle Modification Program Demonstration. Clients attend sessions once a week for three hours for the first 13 weeks, then every other week for the remainder of the 12 months.
Re-evaluation and follow up continue for two more years. This program requires client commitment to independent exercise and the stress relaxation response three times per week and adherence to a healthy diet. Newton-Wellesley also has a one-year long lifestyle modification program, involving yoga, group support, exercise, nutrition education, and actual dinners to introduce the clients to new foods and tastes.
At St. Joseph's Hospital, a new integrated program of exercise and nutrition will open in January that is just for diabetics, who may not necessarily have had a cardiac problem yet. However, with diabetes on the rise and a population that is growing heavier, control of risk factors assumes greater significance.
Information and support provided though cardiac rehab help decrease client relapse into old behaviors, thereby improving health. But only with primary prevention efforts will cardiac events be averted in the first place.