By Serena Agusto-Cox | News & Views
AACVPR’s 2023 Dr. Linda K. Hall Innovation Award was awarded to the University of Pittsburgh Medical Center (UPMC)-Shadyside’s microgym program. The award recognizes a program that uses creativity in patient care and program design to maintain excellence and expand services today and in the future. The initiative brought outpatient cardiovascular rehabilitation (CR) to the inpatient care setting for heart transplant and ventricular assist device (VAD) patients to empower them in their own recovery after discharge.
Jon Ledyard, MS, RCEP, director of cardiopulmonary rehabilitation at UPMC, has worked in heart transplants since the beginning of his 35-year career, and interestingly, one of his mentors early on in his career was Dr. Linda K. Hall. While observing staff working with VAD and transplant inpatients, Ledyard saw that the patients walking the halls were treated similarly. “They would walk them down the hall or as far as they seemed comfortable walking, and then they would return the patients to their rooms,” he said.
Ledyard asked staff to time the walks to gauge how much therapy patients received. Based on 88 sessions evaluated, patients spent an average of only 4.2 minutes walking during a 30-minute visit. “This was shocking to me and the staff,” Ledyard said.
The time and effort staff put in to get transplant and VAD patients ready to walk and navigate interruptions in the halls was longer than the actual walks, according to Ledyard. “That includes the time it took to get the patients out of bed, organize their lines and chest tubes and ensure they were stable enough to walk the halls,” he added. “The total therapy time was really short, and we needed to change that.”
Demonstrate Benefits of Inpatient Access to Cardiovascular Rehabilitation
UPMC-Shadyside assessed how staff could get inpatients engaged with a CR program while still in the hospital, with a goal of reducing readmissions and patient mortality. Ledyard said he believed the family lounge provided the hospital with an opportunity to increase therapy access by creating a microgym.
In meeting with the finance department, he encountered little pushback because he had already identified up to three pieces of unused equipment from the outpatient program that could be repurposed for the inpatient microgym. Additionally, Ledyard said that if you can show how a CR inpatient microgym can translate into real savings for the hospital, finance will make sure that equipment maintenance and other expenses are covered. “For example, if you can reduce length of stay among VAD and transplant patients, the pharmacy expenses for each inpatient also declines,” he explained.
In speaking with inpatient staff, it became clear that two pieces of equipment — the treadmill and NuStep recumbent cross trainer — were the best options for recovering inpatients because they would also enable the maneuvering of patients’ lines, IV poles and chest tubes. “These two pieces of equipment also are the most likely to be used by patients when they enter into outpatient CR programs,” he explained.
Ledyard indicated that for the program to succeed, he needed buy-in from the nurse director and her staff. He explained the benefits of more consistent therapy for patients and how dedicated time for the CR therapy would not disrupt the staff’s normal workflow or the time they spent with each patient. Throughout the process, Ledyard communicated with staff about spacing, workflow and patient therapy to ensure that nurses were still able to complete their daily tasks alongside the therapy with little disruption.
Having the equipment in an accessible place enabled the staff to triple the amount of therapy every patient received. “Right away we were providing patients with sometimes 20 to 30 minutes of exercise instead of 4.2 minutes,” Ledyard explained. “Additionally, we started looking at each patient’s prior functional capacity and what capacity improvements were emerging as a result of the therapy. I encouraged staff to make a greater distinction in the therapy they were providing for a patient based on the previous activity level.”
For example, a 19-year-old heart transplant patient was still being helped out of the chair by staff three days after the onset of therapy. According to Ledyard, this fostered in her a learned helplessness and reliance on the staff. “I began to think about how this sense of dependence could prevent patients who leave the hospital post-surgery from enrolling in outpatient CR programs,” he explained. “The jump from inpatient to walking down the hall, doing barely anything and going to a gym, might be too far of a leap for their mindset unless we get patients working and moving for longer periods and in a targeted way.”
Ledyard added, “We used a behavior change model to help patients move from pre-contemplation to contemplation and from preparation to action. If I can bring patients from pre-contemplation to action while they're in the hospital, it significantly increases the probability that patients will continue the behavior after leaving the hospital.”
Achieving Results and Cost Savings
The microgym demonstrates to the patients what the outpatient CR exercises look and feel like, which Ledyard said, “empowers patients and their families, enabling them to believe that exercise is possible.” In one case, a 24-year-old heart transplant patient, who experienced cardiogenic shock and ended up needing additional organ transplants, went from a sullen patient who only walked the halls with the help of the nurses and his mother to an uplifted patient in the microgym. “His mother was taking pictures, posting them on social media and had a look of optimism about his recovery that wasn’t present before,” Ledyard said. “That was a major incentive to do as much as we possibly could to make the patient believe outpatient CR was possible.”
With the use of an in-hospital microgym, UPMC registered an 8.3% increase in outpatient CR enrollment by new heart transplant patients and a 50% increase in outpatient CR enrollment among new VAD patients. Patients saw their average of 4.2 minutes of therapy provided per session rise to 13.9 minutes of therapy provided per session. The average intensity of inpatient therapy went from 1.5 metabolic equivalent of tasks (METS) to 2.2 METS.
Additionally, post-operative length of stay declined for both new heart transplant patients and new VAD patients. On average, Ledyard pointed out that the duration fell by 1.5 days. “This project improved self-efficacy, overcame learned dependence and improved outpatient CR enrollment,” Ledyard said. “We also did a patient satisfaction survey, and patients gave us glowing remarks about how awesome it was to get in the gym and do the CR exercises. They also pointed out how much better they felt.”
Ledyard said that outpatient CR enrollment has always been a challenge among cardiac patients. He added, “I really believe that the next wave of efforts in CR enrollment needs to address anxiety and self-efficacy. We need to bring people to the point of realizing that they can, in fact, do it.”