How soon is too soon to start cardiac and/or pulmonary rehabilitation?

According to the experts, it's a lot sooner than you'd think.

Four experts weighed in on recent studies that show timing can affect positive outcomes for patients, including increased compliance and completion. It has many in the field considering what needs to be done to reduce the among of time between a hospitalization and rehabilitation, and how that can impact numbers overall.

"When in doubt, I believe our default should be to start rehabilitation as soon as possible," said Quinn Pack, MD, MSc, Medical Director of Cardiac Rehabilitation at Baystate Medical Center. "There might be some increases to minor events--some more symptoms to deal with, might have to do a little bit more monitoring--but faster enrollment appears to be safe and effective." 

Pack said CR patients typically take about a month to two months to get into their programs after they've been released from the hospital. This is for a variety of reasons: Sometimes the referral system requires a stress test or a physician's visit before attending CR, sometimes they're not given the right tools to schedule appointments while they're still in the hospital. One of the major issues is the concern about safety. If a patient is brought into CR or PR too quickly,  is it likely they'll have an event because they were unable to rest?

But Pack pointed to several studies that looked at that. He said data shows patients can get into a rehabilitation program a week after surgery. Moreover, those who were enrolled in the program sooner showed up with more frequency.

For PR patients, researchers saw similar outcomes. Aruna Priya, MA, MSc, a biostatistician with the Baystate Medical Center, said typically PR patients were being enrolled in programs at around 90 days. In a study she and her colleagues performed, they looked at nearly 200,000 patients with COPD, they sought to examine whether timing after hospital discharge affected mortality. She said patients with COPD who were enrolled within 90 days had a better 1-year survival rate, and the earlier they started their PR journey, their outcomes continued to increase (specifically if they started within 30 days of hospital discharge.)

"We needed to see the real world evidence that pulmonary rehabilitation helps these patients," she said. "These  findings support and strengthen that argument."

Research also shows there are significant barriers to getting people into programs faster, which affects their success.

Paula Hardwood, BSN, RN-BC, CCRP, CLSSGB, Manager of Cardiopulmonary Rehabilitation and Heart Failure Services at Memorial Medical Center, said this is a huge problem for clinics across the country. Having cumbersome steps to get people in the door can deter them from going at all, so the sooner patients understand and utilize their CR/PR care, the higher chance they will reap its positive benefits.

It was something she and her team noticed was affecting patients. She said her center used the Lean Six Sigma approach, which measures a five step process to identify areas of improvement. The steps: Identify, Measure, Analyze, Improve, Control. 

By mapping out the challenges both staff and patients face, understanding the measures of success and creating new protocols to eliminate inefficiencies and increase productivity, they were able to reduce the amount of time for enrollment by 71 percent.

"You need to have flexibility and you have to adapt and adjust," Hardwood said. "If you can't find the root of the cause, it's difficult to find a solution that is sustainable over a long period of time."

Steven Keteyian, PhD, FACSM, director of Preventitive Cardiology at the Henry Ford Medical Group, said it's not only important for individual health systems to examine their processes when it comes to referrals, but to gather data outside of the hopsital as well. In Michigan where Keteyian works, there is statewide data available for institutions to compare and contrast overall data from PCI hospitals called the BMC2 Registry. 

He said understanding what percentage of eligible patients are seeking CR in the state and where can help address specific barriers for care. It can also show institutions where there is a higher percentage--like Henry Ford--can help those struggling.

"This has helped us look at some of the big drivers for the lower participation rates," 

Keteyian echoed Hardwood's suggestions: Understanding what weaknesses you have in your own institution can illuminate where the gaps are in getting patients through the door. Something as simple as automatically giving a CR referral for anyone with a cardiac event on discharge paperwork can make a difference. And while some institutions may be set in their ways, he said it's important to speak up and develop a plan.

"There's resistance to change," he said. "I'm asking you to map everything out and start finding low hanging fruit to start picking those off and shorten the discharge to start time." 

This was first presented at at the AACVPR 35th Annual Meeting in Fall 2020.