Potential Risks in Outpatient CR/SP
The safety of CR/SP exercise programs is well established, with very low mortality and myocardial infarction rates during exercise training. An analysis of four reports of exercise-related cardiovascular complications reveals 1 cardiac arrest per 116,906 patient-hours, 1 myocardial infarction per 219,970 patient-hours, and 1 fatality per 752,365 patient-hours. This low fatality rate can be attributed to medically supervised programs that are equipped and prepared to manage adverse events and emergencies.1 However, even when patients are thoroughly screened at program entry and on each day before beginning exercise participation, the potential for the unpredictable occurrence of complications before, during, or after exercise is ever present, particularly as more patients at increased risk of events are entering programs. In 2008, CR/SP participants as a whole were found to be older and less fit than in previous decades, as well presenting more frequently with features of the metabolic syndrome.2
Services offered in hospitals and other facilities that have been accredited by the Joint Commission (TJC) must meet the quality and safety standards established by the accrediting organization.3-6 Minimum guidelines described in this chapter for the management of medical problems and emergencies do not supersede TJC standards but rather complement and further detail the preparation for and delivery of care in cardiac rehabilitation programs at various locations.
Health care advance directives are documents that patients prepare to direct their future health care should they become unable to make such decisions. The most common types of advance directives are living wills and durable power of attorney or health care proxy. When a patient enrolls in CR/SP, the staff should ascertain if advance directives exist; if so, these should be documented and communicated to all staff members. In accordance with the Patient Self-Determination Act, all institutions serving Medicare and Medicaid patients are required to provide information to patients and train health care providers about advance directives and to facilitate the completion of the advance directives if a patient desires them. The outpatient CR/SP setting provides an opportunity for offering this education. Discussions between patients and health care providers regarding patient wishes and desires may lead to a higher prevalence of completion of advance directives.7,8
Patient Assessment and Screening
Although patients have been evaluated before entering the CR/SP program, the clinical status of a patient may change. In addition, risk stratification models and routine diagnostic procedures, such as exercise or pharmacological stress testing, may not identify all patients at risk for exercise training–related events, particularly when they use modes of exercise training other than treadmill walking, such as arm or resistance training. Consequently, it is important to observe patients carefully during a variety of exercise situations and modes.
The staff must be prepared to anticipate and recognize impending problems by evaluating a change in patient condition and providing appropriate intervention. In many cases of impending emergency, patients exhibit warning signs and symptoms. A change in the usual clinical status of a patient with otherwise stable disease can alert the staff to the possibility of a developing medical problem (guideline 12.1). The best approach to managing clinical emergencies is through the early recognition of these signs and symptoms that prompt intervention and treatment.
Guideline 12.2 lists clinical problems CR/SP professionals should recognize and for which they should be prepared to provide immediate intervention. CR/SP program policies and procedures and standing orders should describe specific treatment guidelines (see appendixes N and O for examples). New or changing patterns of signs and symptoms should be reported to the supervising physician, the referring physician, or both.
Angina and Ischemia
Both quality and quantity of chest discomfort or angina equivalent (e.g., atypical chest discomfort, shortness of breath), as well as frequency, duration, and triggers for angina (e.g., physical exertion, exposure to cold, the postprandial period, emotional stressors), should be noted. If angina or ischemic changes occur during supervised exercise, the exercise workload and rate–pressure product (RPP) at which the signs and symptoms appeared should be documented, as well as associated signs or symptoms (e.g., light-headedness, diaphoresis, decreased BP). Ischemia may also create electrical instability resulting in increased dysrhythmias.
Frequency, duration, and type of dysrhythmia(s), including accompanying signs and symptoms, should be noted (e.g., ECG findings of ischemia, light-headedness, dyspnea, poor perfusion). Dysrhythmias to be documented include, but are not limited to, resting and exercise-induced atrial or ventricular ectopy, and tachyarrythmias, as well as atrioventricular block, symptomatic bradycardia, and intraventricular conduction delays (see “Dysrhythmias” section in chapter 9).
Despite having higher overall morbidity and mortality rates, the event rates in exercise training studies in patients with chronic heart failure have been low. The most common events are postexercise hypotension, atrial and ventricular dysrhythmias, and worsening of heart failure symptoms.9 Signs and symptoms such as shortness of breath at rest or with usual activity, weight gain, edema, or decreased exercise tolerance may indicate worsening heart failure and should be noted. Patients with decompensated heart failure should not exercise and should be referred back to their physician or health care provider for evaluation and treatment.
Hypoglycemia or Hyperglycemia
Note pre- or postexercise hypoglycemia or hyperglycemia (in patients with type 1 or type 2 diabetes or insulin-resistant patients), as well as whether it is symptomatic or asymptomatic. Glucose monitoring equipment should be available as well as glucose tablets or gel or other source of carbohydrate. Patients using oral agents, insulin, or both should have a blood glucose of 100 mg/dL or higher during the pre- and postexercise period and should maintain that level during exercise. Patients with hypoglycemia unawareness or frequent hypoglycemia episodes may require a higher blood glucose target or more frequent testing. Avoid exercise in type 1 diabetics with a blood glucose of >300 mg/dL, and use caution in type 2 diabetes.10
Episodes of Syncope or Near-Syncope
Documentation should include the onset, duration, and severity of the episode, along with BP and cardiac rhythm.
Hypotension or Hypertension
Note pre- or postexercise hypotension that is associated with signs or symptoms, persistent resting hypertension, or excessively high exercise BP.
Feelings of dyspnea or shortness of breath can be an angina equivalent or a symptom of respiratory distress. Note the level of activity when symptoms occur as well as lung sounds and oxygen saturation.
Increasing fatigue or level of rating of perceived exertion (RPE) at similar exercise workload and inability to tolerate usual level of activity, as well as abnormal hemodynamic responses to exertion, should be noted.
Patients with new symptoms of claudication should be evaluated by their physician (see chapter 9). A vascular physical examination and ankle–brachial index are recommended. Note onset, duration, and severity of claudication as well as the exercise workload at which symptoms occur. Evaluated patients with intermittent claudication should exercise until they experience moderate to severe discomfort, followed by a brief period of rest allowing symptoms to resolve. Repeat the exercise, rest, exercise pattern throughout the exercise session. Symptoms of critical limb ischemia include resting limb pain, ulceration, or gangrene; these patients should undergo expedited evaluation and should not exercise.11
Depression screening upon entry to the CR/SP program is recommended since depression is often associated with adverse events, increased mortality, and a worse prognosis in cardiac patients. It may double the risk of cardiac events during the first 2 years after myocardial infarction. Although elevated depressive symptoms are relatively common in hospitalized cardiac patients, as many as 15% to 20% of hospitalized cardiac patients meet criteria for major depression, and women and patients with heart failure may have even higher rates.12 Patients who have abnormal initial screenings, persistent depression, or changes in affect should be further assessed to determine necessity for treatment and to rule out risk of suicide. Immediate or elective referral to the primary care physician and a professional qualified in the diagnosis and treatment of depression may be indicated.
Cardiac or Respiratory Arrest
Medical evaluation and risk stratification before starting the CR/SP program and a thorough assessment and screening before each rehabilitation exercise session can assist with identifying unstable patients who should not be allowed to exercise at that time. Prompt recognition of adverse signs and symptoms during the exercise session is essential for the CR/SP staff to be able to either modify or terminate the session before more serious events occur. Quarterly emergency drills are required to ensure that the staff will be able to respond efficiently and effectively if a cardiac or respiratory arrest occurs.