Document Name: Cardiac Rehabilitation Policy for High, Moderate and Low Risk Patients Participating in the Phase III Cardiac Rehabilitation Exercise Programme

Document type: Policy

What does this policy replace?

New

Staff group to whom it applies:

Cardiac rehabilitation in Barnsley BDU

Distribution: Barnsley BDU through clinical policies manual and document store

How to access: Intranet and clinical policies manual

Issue date: November 2012

Next review: November 2015

Approved by: Barnsley BDU Senior Management Team

Developed by: Rachel Smith

Director leads: Transition Director

Contact for advice: Rachel Smith

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CONTENTS

1. Introduction 2 Purpose of this policy 3. Definition 4. Duties 4.1 Barnsley BDU Senior Management Team 4.2 Transition Director 4.3 Deputy Director of Operations 4.4 Service Manager 4.5 All staff 5. Procedure 5.1 Service user inclusion criteria 5.2 Exclusion criteria 5.3 Risk Stratification 5.3.1 Low risk 5.3.2 Moderate risk 5.3.3 High risk 5.4 Health and Safety 5.4.1 Environment 5.4.2 Staffing 5.4.3 Unwell Patient 5.5 Consent 5.6 Assessment 5.7 Exercise Programme 5.7.1 Monitoring each session 5.7.2 Warm up 5.7.3 Types of Exercise 5.7.4 Cool down 5.8 Discharge Planning 6. Development process 6.1 Identification of need 6.2 Stakeholder involvement 6.3. Equality Impact Assessment and Review & Approval Checklist 7. Approval and Review Process 8. Version control 9. Dissemination 10. Implementation 11. Document Control and Archiving 12. Monitor compliance 13. Associated documents and supporting references

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Appendix 1 Appendix 2 Appendix 3 Appendix 4 Appendix 5 Appendix 6 Appendix 7

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Cardiac Rehabilitation Policy for High, Moderate and Low Risk Patients Participating in the Phase III Cardiac Rehabilitation Exercise Programme 1. Introduction Cardiac rehabilitation is a structured programme designed to deliver education and exercise to patients following a cardiac event. Four phases make up the full programme and are each tailored to provide the appropriate information at the relevant stage of recovery. Phase I: Acute stage in hospital. Phase II: Interim period between hospital discharge and commencement of exercise component. Education can begin during this phase. Phase III: Exercise component of rehabilitation Phase IV: Ongoing management by the patient. During Phase I-III the responsibility for the care of the patient is that of the consultant cardiologist. As they enter phase IV they are no longer under the care of the consultant and care is transferred to the GP. 2 Purpose of this policy This policy has been produced to identify clear guidelines to support the delivery of the phase III exercise component of cardiac rehabilitation, based at Dorothy Hyman Sports Centre, by South West Yorkshire Partnership NHS Foundation Trust. The aim of this policy is to ensure best practice when carrying out assessments and delivering the exercise component for patients attending cardiac rehabilitation that are categorised as low, moderate and high risk under the risk stratification criteria that will be clearly set out within the document. 3. Definition Cardiac rehabilitation is defined as: ‘The sum of activities required to influence favourably the underlying cause of the disease as well as the best possible, physical, mental and social conditions, so that people may, by their own efforts preserve or resume when lost, as normal a place as possible in the community. Rehabilitation cannot be regarded as an isolated form or stage of therapy but must be integrated within the secondary prevention service of which it forms only one facet’ (World health organisation expert committee 1993)

4. Duties 4.1 Barnsley BDU Senior Management Team The Barnsley BDU Senior Management Team will approve the policy. They will be responsible for ensuring the policy document has been developed according to this Policy for the development, approval and dissemination of policy and procedural documents (Policy on Policies)

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4.2 Transition Director As accountable officer for Barnsley BDU, the Transition Director is the lead for the policy, will ensure appropriate consultation, approval, dissemination and implementation. 4.3 Deputy Director of Operations

The Deputy Director of Operations has accountability and responsibility for ensuring the policy is in place and is implemented within Barnsley BDU.

4.4 Service Manager It is the responsibility of the Service Manager to:

• Ensure sufficient resources in staffing and equipment are available to implement the policy.

• Take remedial action where an employee fails to comply with the requirements set out in this policy

4.5 All staff All staff will be aware of the policy and bear in mind the content when treating patients. 5. Procedure 5.1 Service user inclusion criteria The aim of this service is to provide exercise sessions within a safe environment for patients with the following conditions:

• Post acute myocardial infarction o NSTEMI (medical management or percutaneous coronary

intervention) o STEMI (medical management or primary percutaneous coronary

intervention)

• Acute coronary syndrome

• Revascularisation o Coronary artery bypass graft o Elective percutaneous coronary intervention

• Stable angina

• Stable heart failure

• Post EECP

• Valve surgery

• Implantation of device (permanent pacemaker/ implanted cardioverter defibrillator)

• Post total heart transplant

• Aortic root replacement All of these patients will need to be committed and motivated to lifestyle changes to ensure that they achieve their full potential.

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5.2 Exclusion criteria

• Unstable angina

• Uncompensated congestive heart failure

• Severe aortic stenosis

• Resting hypertension. systolic > 180mmHg/ diastolic > 100mmHg

• Resting hypotension. systolic <90mmHg/ diastolic < 50mmHg

• Orthostatic blood pressure drop of >20mm/Hg with symptoms

• Uncontrolled atrial or ventricular arrhythmias

• Tachycardia > 100bpm

• Resting ST segment displacement > 2mm

• Acute systemic illness or fever

• Acute pericarditis or myocarditis

• Musculoskeletal problems that would prevent participation (even when modified)

• Uncontrolled medical co-morbidities.

• Psychological state would make participation in a class inappropriate All of patients with the above considerations would not be deemed appropriate to participate in the exercise component of cardiac rehabilitation. 5.3 Risk Stratification All patients need to be risk stratified and identified as low, moderate or high risk. Exercise will be beneficial for all patients that are suitable to attend rehabilitation. However, the level of intensity of the exercise would be determined by the risk stratification. 5.3.1 Low risk Patients that are categorised as low risk would be suitable to work at the highest intensity exercise group. The factors that would determine them as low risk would be:

• Uncomplicated myocardial infarction or revascularisation procedure

• No complex ventricular arrhythmia at rest, during exercise and at recovery

• No angina or associated symptoms during exercise and recovery

• No congestive heart failure

• Normal haemodynamic response during exercise and recovery

• Functional capacity > 7 METS

• No significant left ventricular dysfunction. Resting ejection fraction > 50%

• No ischaemia post event/procedure either at rest or during exercise

• No signs of clinical depression 5.3.2 Moderate risk Moderate risk patients are categorised as those who the following factors would apply to:

• Angina symptoms when exercised at high intensity levels (> 7 METS)

• Mild to moderate level of silent ischaemia during exercise and recovery (<2mm ST depression from baseline)

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• Function capacity < 5 METS

• Moderately reduced left ventricular dysfunction. Resting ejection fraction 40-49%

5.3.3 High risk The patients that are categorised as high risk can have any one of the following factors:

• Presence of complex arrhythmias at rest or developing during exercise and recovery

• Angina symptoms when exercising at low intensity levels (< 5 METS)

• High level of silent ischaemia during exercise and recovery (>2mm ST depression from baseline)

• Severely reduced left ventricular function. Resting ejection fraction < 40%

• History of cardiac arrest

• Decrease in systolic blood pressure of > 15mmHg during exercise or recovery

• Complicated myocardial infarction or revascularisation procedure

• Presence of signs and symptoms of post event/procedure ischaemia

• Presence of clinical depression 5.4 Health and Safety Health and safety will be maintained throughout by adhering to the SWYPFT health and safety policy (See Trust policy). The most important issue when exercising is maintaining patient safety. This is why a detailed assessment of the patient is carried out before any exercise is advised. The patient will also be screened prior to commencement of every exercise session to ensure that there have been no changes with their medication or general health or adverse effects of exercise since the previous session. The patients will also have their blood pressure and heart rate recorded so they are within safe parameters. Resuscitation equipment will be kept in the room and staff will be competent in its use having undergone intermediate life support training inline with trusts cardiopulmonary resuscitation policy. The equipment will be maintained in accordance with SWYPFT provision and use of work equipment regulations. Drinking water is available at all times. 5.4.1 Environment The room size must be adequate to provide good ventilation and ensure that the patients can move freely between the equipment and other members of the group. Equipment with protruding edges are marked with high visibility stickers to make them more apparent to patients to avoid trips and falls. The equipment is wiped down and cleaned between patient use to decontaminate it (See SWYPFT infection, prevention and control policy).

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The temperature of the room should be maintained between 18-22°C. The air conditioning unit in the room ensures that this is possible throughout the year. 5.4.2 Staffing The staffing levels of the group should be targeted as five patients to one trained member of staff. This can be varied depending on the risk category of the group to 4:1 for the high risk patients who may require closer monitoring. All of the exercise sessions should be led and supervised by competent staff. All of these will be trained in intermediate life support. There should be a minimum of two trained staff present during all exercise sessions. 5.4.3 Unwell Patient As previously mentioned, all patients will be screened prior to each session to ensure that they are suitable to exercise but, if a patient becomes unwell during an exercise session, the ‘unwell patient’ procedure should be adhered to (See Appendix 1). The trained nurses on site or the designated first aider in the building will administer first aid if required. 5.5 Consent All patients need to give their consent to commence the exercise component of cardiac rehabilitation. A full explanation of the treatment should be given, highlighting the benefits, risks and side effects involved. The patient will then have the opportunity to ask questions and informed of their right to decline treatment at any time. The patients consent should be documented in their notes. If the patient does not have capacity to consent for themselves, Trust procedure when patients lack or withhold consent will be followed (See Trust policy for consent to examination or treatment). 5.6 Assessment All patients will attend for an assessment prior to commencing in a rehabilitation group. The assessment will be completed by a competent member of staff who will firstly ask the patient if there have been any changes in their symptoms, treatment or medication since they were last seen by the cardiac nurse. If there have been any changes, the member of staff will clinically reason whether the patient is still appropriate to continue with exercise and seek guidance from a senior member of staff if necessary. If deemed appropriate to exercise, the patient will be inducted with information relating to the following given out:

• Appropriate clothing and footwear to exercise in

• Pulse and blood pressure monitoring

• Appropriate exercise intensity

• Importance of warm up and cool down

• Appropriate use of exercise equipment

• Using rate of perceived exertion (RPE) (See Appendix 2)

• Training heart rate (See Appendix 3)

• Benefits of exercise

• Informing staff of any change in symptoms when exercising

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• Bringing any medication needed for exercising (GTN, inhalers)

• Reporting any changes in medication prescription

• If they have a latex allergy

• Contraindications to exercise Part of the initial assessment involves completing a shuttle walking test to determine the patients pre-rehabilitation exercise capacity. When the patient has completed the initial assessment, they will be assigned accordingly to one of the exercise groups, which the competent member of staff feels will be most suitable for them. 5.7 Exercise Programme Together with the medical findings and the details of the initial assessment an individual exercise programme will be developed with the patient. Any modifications that need to be made to the programme will have been identified in the initial assessment. Individual goals and outcome measures can be recorded and reviewed throughout the programme. The patients will be invited to attend the exercise groups twice per week and the entire programme will last between eight and twelve weeks depending on the group that the patient is assigned to. 5.7.1 Monitoring each session At the beginning of each session, every patient will be asked if there have been any changes since their last attendance in their health or medication and as such advised if it is appropriate for them to continue with the exercise. A record of the patient’s blood pressure and heart rate will also be taken. If a patient requires any precautionary medication to exercise, such as, GTN or inhalers, they will be asked if they have brought it with them. If the patient informs a member of staff that they have not brought their medication with them, they will be told that they are unable to exercise. The patient will also be unable to exercise if they have not taken their daily prescribed medication. The patient will wear a cardiac monitor that will keep a continual check of their heart rate. They will be asked at various intervals during the session to write down what their heart rate is. 5.7.2 Warm up Every patient, regardless of exercise intensity, will complete a warm up. This may be a staff led warm up where all the patients follow a structured routine or it will be a timed lower intensity exercise such as a walking circuit. The warm up should last between 6-10 minutes depending on the intensity of the group. Each patient should aim to increase their heart rate in order to prepare the body for exercise and be working at a rate of perceived exertion score of 9-11 5.7.3 Types of Exercise There are four exercise groups that patients can be assigned to:

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Rehab 1: Low risk This group consists of exercising at 9 stations for 3 minutes per station (See Appendix 4). The time between each station should be no longer than 20-30 seconds. The intensity of this group should be fairly high and the patients can work more autonomously by recording their own heart rate and RPE scores. Rehab 2: Moderate risk The patients work for 6 minutes per station and there are 5 stations formulated by the person instructing on exercise. These will be recorded on an exercise sheet. The time between each station is longer giving the patient longer to recover. Following each station the patient will be asked what their heart rate is and their RPE plus any objective measurement and the data recorded on the exercise sheet. Rehab 3: High risk The patients again work for 6 minutes on each of the 5 individually prescribed stations but at a lower level of intensity. The heart rate and RPE will be recorded after each station Heart failure/Angina/EECP This group is specifically for patients with the above diagnosis/ treatment intervention. They will often work to RPE rather than a target heart rate. The group consists of 5 individually selected stations and patients work for 6 minutes per station. 5.7.4 Cool down All patients participate in a cool down period which involves low intensity activity to allow the body to recover from exercising gradually. After the cool down the patients record their heart rate then have a further rest period when the heart rate should return to within 10 beats of the pre-exercise heart rate. 5.8 Discharge Planning After the patient has completed the rehabilitation sessions they will be discharged from the programme with hopefully a basic understanding of their condition and its management. They will complete a second shuttle walking test to reassess their exercise capacity and determine the progress that they have made over the course of their treatment. On discharge the patient will also be made aware of local Phase IV sessions that are available to them and a discharge letter provided if necessary. 6. Development process 6.1 Identification of need This document is in place to ensure the safe provision of patients whilst attending cardiac rehabilitation. 6.2 Stakeholder involvement

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The following stakeholders have been involved with the development of this document

Stakeholder Level of involvement

Barnsley BDU senior management team

Approval

Barnsley BDU policies and procedures group

Consultation, dissemination and implementation

Specialist staff Development, consultation, dissemination, implementation and monitoring

6.3. Equality Impact Assessment and Review & Approval Checklist Completed and provided as Appendices 5 and 6

7. Approval and Review Process

As the policy is for Barnsley BDU, it has been approved by the Barnsley BDU Senior Management Team. As a policy, it will be reviewed three years after approval.

8. Version control

See Appendix 7

9. Dissemination Once approved, the Governance Manager will be responsible for ensuring the updated protocol is added to Document Store and Barnsley BDU Manual. If local teams down load and keep a paper version of procedural documents, the manager must identify someone within the team who is responsible for updating the paper version when a policy change is communicated via the staff brief. 10. Implementation Ensure that staff are aware of the policy and given the support required to meet its aims 11. Document Control and Archiving

• The current policy will be available on the intranet in read only format.

• A paper copy will be retained in the manuals

• Documents will be retained in accordance with requirements for retention of non-clinical records.

12. Monitor compliance

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The service will be monitored through audit, supervision of staff, incident reporting and patient and public involvement questionnaires. 13. Associated documents and supporting references This document has been developed in line with SWYPFT policy for the development, approval and dissemination of policy and procedural documents. It should be read in conjunction with:

• Provision and use of work equipment regulations

• Policy for consent to examination or treatment

• Cardiopulmonary resuscitation policy

Appendix 1

Unwell Patient Procedure

For use when a patient becomes unwell during an

exercise session This policy would be called into use if:

• The patient exhibits any of the following: o Diabetic emergency- hypoglycaemia o Abnormally hypotensive o Epileptic fit o Collapse

• The patient demonstrates the following signs and symptoms o Clammy o Short of breath o Chest pain o Fainting o Dizziness

Action 1. Call 999 and ask for ambulance assistance 2. Make the patient comfortable and start O2 therapy 3. Reassure other patients 4. Have equipment nearby ready for staff coming to assist

If the patient is assessed and deemed as fit to go home:

• Decide if they are fit to drive themselves

• If they are not suitable to drive contact a person of the patients choosing to collect them or send home by taxi

• Ask the patient to contact their GP if necessary The rest of the exercise group should be managed accordingly

• Staff not involved with the patient’s treatment should reassure the remaining class members

• If appropriate the class should continue

• If inappropriate the class should be stopped and the rest of the patients sent home

Appendix 2

Rate of Perceived Exertion Scale (RPE) by BORG 6. No exertion at all 7. Extremely light 8. 9. Very light 10. 11. Light 12. 13. Somewhat hard 14. 15. Hard (Heavy) 16. 17. Very hard 18. 19. Extremely hard 20. Maximal Exertion Whilst you perform your exercise consider how breathless you are and how hard the exercise feels. Choose the number that reflects how breathless you feel. You should be aiming to work at 10-13 on the scale but most exercises should be in the range of 11-12. This scale is for how you feel and so the opinion of others does not matter much.

Appendix 3

Heart Rate Guide for Fitness Training

100% maximum heart rate possible 85% generally recommended level –week 6 onwards

80% 75% minimum level for training effect – week 6 onwards 70% 65% Rehab 1 – start level for effective training – week 1 N.B. If on Betablockers the heart rate will be LESS than the above states due to the effects of the medication.

200

195

190

185

180

175

170 170

160 165 165

155 160 160

150 155 155

145 155 150

150 145 150 145

140 145 140 145

135 140 135 140

130 140 130 135

130 135 125 130

125 130 125 125

130 120 130 115 120

125 120 125 115

125 115 120

120 110 115

115 105 110

115 100 105

110 95

110

105

100

100

95

20 25 30 35 40 45 50 55 60 65 70 75

Appendix 4

Rehab 1 Gym setup

7. Upper Limb

Dumbbells

8. Step over

9. Schwinn Cycles

6. Shuttle walk with step over

4. Step up

3. Theraband

Exercises

2. Rowing

machines

5. Schwinn Cycles

1. Monark bikes

Appendix 5 - Equality Impact Assessment Tool .

Equality Impact Assessment Questions:

Evidence based Answers & Actions:

1

Name of the policy that you are Equality Impact Assessing

Cardiac Rehabilitation Policy for High, Moderate and Low Risk Patients Participating in the Phase III Cardiac Rehabilitation Exercise Programme

2

Describe the overall aim of your policy and context? Who will benefit from this policy?

To provide a clear outline of the cardiac rehabilitation service and ensure safe provision for the patients. The staff and the patients

3 4

Who is the overall lead for this assessment? Who else was involved in conducting this assessment?

Transition director Cardiac Rehabilitation team

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Have you involved and consulted service users, carers, and staff in developing this policy? What did you find out and how have you used this information?

Members of the Barnsley BDU senior management team and clinical policies and procedures group N/A

6 7

What equality data have you used to inform this equality impact assessment? What does this data say?

N/A N/A

8

Taking into account the information gathered. Does this policy affect one group less or more favourably than another on the basis of:

YES NO

Race N

Disability N

Gender N

Age N

Sexual Orientation N

Religion or Belief N

Transgender N

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Carers

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What monitoring arrangements are you implementing or already have in place to ensure that this policy:

• promotes equality of opportunity who share the above protected characteristics

• eliminates discrimination, harassment and bullying for people who share the above protected characteristics

• promotes good relations between different equality groups,

The service will be monitored through audit, supervision of staff, incident reporting and patient and public involvement questionnaires

10

Have you developed an Action Plan arising from this assessment?

N/A

11

Who will approve this assessment and when will you publish this assessment.

Barnsley BDU senior management team

12 Once approved, please forward a copy of this assessment to the Equality & Inclusion Team: inclusion@swyt.nhs.uk

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Appendix 6 - Checklist for the Review and Approval of Procedural Document

Title of document being reviewed: Yes/No/ Unsure

Comments

1. Title

Is the title clear and unambiguous? YES

Is it clear whether the document is a guideline, policy, protocol or standard?

YES

Is it clear in the introduction whether this document replaces or supersedes a previous document?

YES

2. Rationale

Are reasons for development of the document stated?

YES

3. Development Process

Is the method described in brief? YES

Are people involved in the development identified?

YES

Do you feel a reasonable attempt has been made to ensure relevant expertise has been used?

YES

Is there evidence of consultation with stakeholders and users?

YES

4. Content

Is the objective of the document clear? YES

Is the target population clear and unambiguous?

YES

Are the intended outcomes described? YES

Are the statements clear and unambiguous? YES

5. Evidence Base

Is the type of evidence to support the document identified explicitly?

YES

Are key references cited? YES

Are the references cited in full? YES

Are supporting documents referenced? YES

6. Approval

Does the document identify which committee/group will approve it?

YES

If appropriate have the joint Human Resources/staff side committee (or equivalent) approved the document?

N/A

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Title of document being reviewed: Yes/No/ Unsure

Comments

7. Dissemination and Implementation

Is there an outline/plan to identify how this will be done?

YES

Does the plan include the necessary training/support to ensure compliance?

YES

8. Document Control

Does the document identify where it will be held?

YES

Have archiving arrangements for superseded documents been addressed?

YES

9. Process to Monitor Compliance and Effectiveness

Are there measurable standards or KPIs to support the monitoring of compliance with and effectiveness of the document?

YES

Is there a plan to review or audit compliance with the document?

YES

10. Review Date

Is the review date identified? YES

Is the frequency of review identified? If so is it

acceptable?

YES

11. Overall Responsibility for the Document

Is it clear who will be responsible implementation and review of the document?

YES

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Appendix 7 - Version Control Sheet

Version Date Author Status Comment / changes

1 June 2012

Cardiac Rehabilitation Team