Improving Functional Capacity in Cardiac Rehab Patients

A few years ago, Cleveland Clinic Marymount Hospital began pursuing certification of its cardiopulmonary rehabilitation program through the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR). “When we started down the path to certification, we began looking closely at patient outcomes,” says Amy Cunningham-Mays, BSN, RN, a clinical nurse in Marymount Hospital’s cardiac rehabilitation program. “We realized we had an issue with our functional capacity outcomes.”

A review of 4Q 2017 cardiac rehab patients indicated that only 38.5% had achieved an improvement in functional capacity of at least 40% as measured by metabolic equivalent (MET) levels. MET is a ratio of a person’s metabolic rate during any given activity relative to their resting metabolic rate. The AACVPR considers an increase of METs by at least 40% as a clinically significant improvement. A multidisciplinary team of caregivers in the cardiac rehabilitation program launched an initiative in 2018 to improve functional capacity by 40% or more in at least 75% of its patients.

A three-tiered approach to improvements

Cunningham-Mays worked on the project with another clinical nurse, the nurse manager, an exercise physiologist and a respiratory therapist. “We began by looking at what we were doing as a team and what we needed to start doing to improve our patients’ functional capacity,” she says. “The team effort was important to make this work – getting everyone’s input based on their area of expertise and skill set.”

Based on a literature review, conversations among the team and consideration of the patient population that uses Marymount Hospital’s cardiac rehab program (mostly elderly), the team implemented a three-pronged approach to improving functional capacity.

1. Use detailed individualized treatment plans (ITPs). The program already used ITP reports to set broad goals that are reviewed every 30 days by staff and the medical director. The team began creating more robust reports by establishing specific goals geared toward each patient and sending the plans to physicians for review. For instance, if a patient has an orthopaedic issue, then the ITP will indicate any limitations in range of motion and reflect this in treatment plans.
2. Create patient cards and visual management boards. Each patient who participates in cardiac rehab has a card including their name, a list of the exercises and equipment they use, and a goal for each exercise. The goals change as the patient progresses, encouraging them to increase workloads and activity levels. The patients’ exercise workloads are also displayed on a visual management board in the cardiac rehab gym to help inspire them.
3. Develop an educational session on home exercise. “We realize that it’s not enough for patients to only do three days of exercise during cardiac rehab sessions,” says Cunningham-Mays. The exercise physiologist began offering home exercise counseling focused on ways to increase patients’ levels of physical activity by at least 2.5 hours a week. Because many patients are elderly and do not have exercise equipment at home, she provides tips such as using canned goods as hand weights and using stretch bands for seated activities while watching TV.

“After we started doing these three things, we looked at our MET numbers again,” says Cunningham-Mays. “We had an excellent response!” During 4Q 2018, 62.5% of cardiac rehab patients had improved their functional capacity by 40% or more. In 2019, an average of 76% of patients increased their functional capacity by 40% or more, surpassing the goal the team set at the outset of the project.

Interventions empower rehab patients

During 2020, most patients’ fitness levels declined, says Cunningham-Mays. The cardiac rehab program was closed from mid- March through mid-June because of COVID-19, and many patients remain uncomfortable going to a local gym. But Cunningham-Mays is optimistic that patients are now beginning to “get back into the exercise groove.”

Involving patients in the creation of fitness goals and encouraging them to increase their activity has improved overall patient experience with cardiac rehab. “The patients like being in charge of their own exercise and being held accountable,” says Cunningham-Mays. “It empowers them.”

The cardiac rehab program has also benefitted from improved outcomes. Marymount Hospital was named a Certified Cardiac Rehabilitation Program by AACVPR in August 2019, becoming one of 19 Cleveland Clinic facilities to earn certification for cardiovascular or pulmonary rehab programs from the association.

“Once we realized we had a problem with functional capacity levels and utilized everyone’s area of expertise to solve the problem, the whole puzzle came together,” says Cunningham-Mays.