Cardiac rehabilitation in Dumfries and Galloway: a model for rural areas?

Coronary Health Care (1997)1,138-144 9 1997PearsonProfessionalLtd

ORIGINAL A R T I C L E

Cardiac rehabilitation in Dumfries and Galloway: a model for rural areas? L. L. Lockhart, C. G. Isles, K. McMeeken, S. J. Cross, J. Mark, G. W. Tait Cardiac Rehabilitation and Medical Unit, Dumfries and Galloway Royal Infirmary, Dumfries, UK SUMMARY. Objective: To ensure that patients are not excluded from cardiac rehabilitation simply because they live at a distance from their local hospital. Design: a series of developments over six years that have included use of the Heart Manual; training of 80 community-based Heart Manual Facilitators; creation of an outreach Cardiac Rehabilitation Sister's post; development of a patient-held discharge record and follow-up form; extension of outpatient cardiac rehabilitation to six centres. Setting: Dumfries and Galloway, in south west Scotland - a predominantly rural area with a widely dispersed population of 148 000. Patients: All men and women admitted to the Medical Intensive Care Unit in Dumfries with suspected myocardial infarction. Main o u t c o m e m e a s u r e s : The proportion of myocardial infarction patients who received inpatient and outpatient cardiac rehabilitation, and the proportion of those discharged with a Heart Manual who received a home visit. Results: An audit of cardiac rehabilitation activity in 1994, at a time when we held outpatient classes in three centres rather than six, showed that 86% of myocardial infarction survivors received inpatient cardiac rehabilitation, and that 35% of this group completed at least five sessions of an eight-week outpatient cardiac rehabilitation class (or four or more sessions of a six-week class for over-65s). Women were as likely to receive inpatient cardiac rehabilitation as men but less likely to complete outpatient cardiac rehabilitation. Similar trends were seen for the elderly. During the latter half of 1994, 83% of myocardial infarction patients who had been discharged with a Heart Manual were visited at home by a Heart Manual Facilitator. Conclusions: We believe that our model of cardiac rehabilitation has established a vital link between hospital and community. Not only should this facilitate the universal provision of cardiac rehabilitation across a large rural area, but also it should enable patients at highest risk to be targeted for treatment. This may answer the criticism that cardiac rehabilitation programmes select only low-risk patients, for whom the benefits of cardiac rehabilitation may be marginal.

psychosocial treatment on rehabilitation from documented coronary artery disease was evaluated, found benefits for mortality, morbidity, psychological distress and some biological risk factors (Linden et al 1996). By contrast, a recently published single trial (too late for the meta-analysis) of 2328 MI survivors who received psychological therapy, counselling, relaxation and stress-management training, found no differences at 12 months in clinical complications, clinical sequelae or mortality (Jones & West 1996). The author of an accompanying editorial, while commending CR, concluded that CR programmes should be redesigned 'to offer simple, flexible and cost effective help that is psychologically and cardiologically informed' (Mayou 1996).

INTRODUCTION Cardiac rehabilitation (CR) has been defined as the process by which patients with cardiac disease achieve their optimal physical, psychosocial, emotional and vocational status (Chua & Lipkin 1993). In the late 1980s, two meta-analyses reported a 20% reduction in cardiovascular death among patients randomized to an exercise programme after a myocardial infarction (MI) (Oldridge et al 1988; O'Connor et al 1989). The benefit associated with exercise-based rehabilitation programmes is likely to be due in part to risk-factor modification, in part to increased patient surveillance and in part to exercise training. The evidence o n psychological rehabilitation after MI is conflicting. A meta-analysis of 23 randomized trials comprising 3180 patients, in which the additional impact of

METHODS Correspondence to: Dr Christopher Isles, Medical Unit, Dumfries and Galloway Royal Infirmary, Dumfries, D G I 4AP, Fax: 01387 241639

The creation of a part-time Cardiac Rehabilitation Sister's post in Dumfries in April 1990 was made 138

A model for cardiac rehabilitation in rural areas

139

Moffat

Lockerbie

Port W i l l i a m

Population covered = 120 600

Fig. 1 Map of Dumfriesand Galloway.All shadedareasare withinten milesof an exerciseclass.

possible by grants from the Chest, Heart and Stroke Association, British Heart Foundation and pharmaceutical industry. This enabled us to provide inpatient CR to most MI patients and outpatient CR to those living in or near Dumfries. A total of 50 000 people live within ten miles of the Infirmary, which we felt was close enough for patients to attend an exercise class if invited to do so (Fig. 1). The service proved popular with patients and a second part-time Cardiac Rehabilitation Sister was appointed in June 1992 to help with the expanding workload and to allow additional community-based classes to be set up in Newton Stewart and Sanquhar. This meant that an additional 10 000 patients were then able to benefit (Fig. 1). Funding came initially from the pharmaceutical industry until May 1993, when the Health Board approved the post, on the condition that CR was realigned to provide facilitation and training of Community Nurses throughout the region with a view to setting up local programmes. The Heart Manual Following the publication of the work describing the use of the Heart Manual in the rehabilitation of postMI patients (Lewin et al 1992), we adopted the Heart Manual as the tool we would use for our own programme. The Heart Manual comprises six weekly sections that cover home-based exercises, stressmanagement, education, and includes a tape-based

relaxation programme. It provides specific self-help treatments for intrusive and distressing thoughts, anxiety, depression, undue illness behaviour, panic disorder and other psychological problems commonly experienced by post-MI patients. The advantages to us of using the Heart Manual were that it had already been validated, patients liked it and nurses could be trained to use it in two days. Training of community nurses A grant from the Queen's Nursing Institute (Scotland) in 1994 enabled us to train Community Nurses from each of the 37 practices in Dumfries and Galloway to use the Heart Manual. At least two nurses were trained per practice to ensure that nurses were not working in isolation. We felt it was important to choose nurses showing the greatest interest in Cardiac Rehabilitation, be they Health Visitors, Practice Nurses or District Nurses, rather than limit the offer of training to nurses from any one of these groups. This strategy proved successful and, by the end of 1995, 80 Community Nurses, together with a further 19 nurses from the Acute Units in Dumfries and Galloway, had learned how to administer the Heart Manual to patients recovering from an MI. Initially, training took place in Edinburgh but, during 1994, one of us (KMcM) became a Heart Manual Facilitator Trainer, enabling us to run further Heart Manual training sessions locally. We also provide

140

Coronary Health Care HEART PATIENT DISCHARGE RECORD AND FOLLOW-UP FORM PATIENT DETAILS Date of referral: Hospital number: In-patient [ ] Out-patient [ ] GP: Consultant:

Name:

Address: Telephone: Occupation: CommunityNurse:

DIAGNOSES Angina ~ Diabetes Other

Heartattack ~ COAD

Bypass surgery ~ Arthritis

Angioplasty ~ PVD [._J

MODIFIABLE RISK FACTORS Yes No

Smoking High blood pressure Cholesterolmeasured Overweight Adviceon diet Adviceon exercise HAD Score

Amt/day=

When stopped :

Chol: Weight:

Trig: Hi:

A~

D=

HDL: BMI:

Ratio:

LEAVING HOSPITAL Yea No

Drug and Dose

Aspirin Betabloeker ACE inhibitor Cholesterollowering Other drugs Pre-diseharge exercisetest Eehoeardiogram Heart manual given OP rehabilitationarranged Comments Signature : Fig. 2 Discharge record and follow-up form issued to MI patients and community nurses

ongoing in-service training for Community Nurses every six months. Creation of outreach CR sister's post

The most recent development in our CR programme, starting in April 1996, has been the appointment of an Outreach CR Sister, based in Dumfries Infirmary but with strong community links. The creation of this post was made possible by a two-year grant from the British Heart Foundation and our own Health Board. The specific remit of the Outreach Sister is to extend CR into rural areas and target those at highest risk. Patient-held discharge record and follow-up form By issuing all patients and their Community Nurses with a two-page discharge record and follow-up form

(Fig. 2), again since April 1996, we aim to ensure that patients in need of further assessment, either physically or psychologically, do not lose out just because they live a long way from the Infirmary. An additional advantage of a patient-held record is that patients may feel encouraged to take increased responsibility for their own health (Jackson 1995). Extension of outpatient cardiac rehabilitation to six centres The creation of the Outreach Sister's post has allowed us to establish community-based outpatient CR programmes in an additional three centres (making a total of six centres), which means that no fewer than 120 600 (81%) of our predominantly rural population now live within ten miles of an exercise class (Fig. 1).

A model for cardiac rehabilitation in rural areas

141

F O L L O W U P A T 6 W E E K S BY C O M M U N I T Y N U R S E

Name :

Hospital number : Yes

No

Chest pain on effort Breathless on effort Smoking

Amt/day

BP check

BP=

Overweight

Weight =

Home visit H A D score

A=

Lifestyle advice given Drug changes Medical/Cardiology follow up arranged

eg smoking,diet,exercise,driving,work,sex,travel

Signature :

Date :

D=

Details Details

Please complete this section and return form to Sister Loekhart RECOMMENDATIONS

Yes Continue Heart Manual Personal counselling Fasting cholesterol (due Hospital rehabilitation class Community rehabilitation class Further cardiological assessment Refer psychology Refer dietitian Refer physiotherapist Discharge to GP

No

eg exercise test, echo

NOTES

Signature : Fig. 2

Discharge record and follow-up f o r m

Dale

(continued).

RESULTS In Dumfries and Galloway, the vast majority of patients with suspected MI are admitted to the Medical Intensive Care Unit in Dumfries Infirmary with no selection on the basis of age or gender. Thereafter, all patients with proven MI, unstable angina, myocardial ischaemia and ischaemic heart disease are eligible for CR, as are those returning from Glasgow following coronary angioplasty or a coronary artery bypass graft (CABG). As a result, 1794 patients have received inpatient CR, and 649, including 152 post-surgery patients, have completed a six-to-eight-week outpatient class, during the past six years. Table 1 shows the evolution of our Cardiac Rehabilitation service and the different categories of patients seen. Several trends are apparent. It is evident that an increasing number of older patients

are being referred for CR, so that 50% of all patients are now aged 65 years or over. The number of patients attending and completing an outpatient rehabilitation class increased from 49 in 1990 to 142 in 1995, reflecting increasing enthusiasm for this form of activity and the use of outlying Health Centres for patients living at a distance from the Infirmary. Table 1 also shows that, starting in 1992, 348 patients have been discharged from hospital with a Heart Manual. An audit of CR activity in 1994 (at a time when we held outpatient classes in Dumfries, Sanquhar and Newton Stewart, and 60 000 of our population of 148 000 were living within ten miles of one of these centres) showed that 232/269 (86%) MI survivors received CR while in hospital (Table 2) and that 82/232 (35%) of those seen as an inpatient went on to complete at least five sessions of an eight-week outpatient class (or four or more sessions of a six-week

142

Coronary Health Care Table 1 Evolution of cardiac rehabilitation in Dumfries and Galloway (1990-1995)

1990

1991

1992

1993

1994

1995

Men Women <65 years > 65 years

114 54 90 78

223 101 196 128

248 109 188 169

243 108 182 169

245 92 168 169

284 136 214 206

Total

168

324

357

351

337

420

IP rehab OP rehab < 65 years OP rehab > 65 years OP rehab post CABG

156 49 0 5 0

305 73 4 13 0

339 90 15 18 9

319 100 40 29 92

306 98 38 43 117

369 85 57 44 130

Heart Manual

Abbreviations: IP rehab, inpatient rehabilitation; OP rehab, outpatient rehabilitation; CABG, coronary artery bypass graft.

Table 2 Audit of MI admissions (1994)

Men

Women

Both

MI admissions Died during admission MI survivors

226 35 191

97 19 78

323 54 269

MI survivors referredforlP CR < 65years 65 years

167 (87%) 76 91

65 (83%) 23 42

232 (86%) 99 133

68 (41%) 45 23

14 (22%) 8 6

82 (35%) 53 29

Mlsurvivorscompleting OP CR < 65 years 65 years

Abbreviations: MI, myocardial infarction; IP CR, inpatient cardiac rehabilitation; OP CR, outpatient cardiac rehabilitation Note: MI survivorscompleting CR are given as a proportion of those who were referred for IP CR.

class for over-65s). Equal proportions of men and women received inpatient CR, but fewer women (22%) than men (41%) went on to complete an outpatient class (Table 2). Patients over 65 years comprised 133/232 (37%) of M I inpatients seen by the C R sisters, but only 29/82 (35%) of those M I patients who completed an outpatient class. An outpatient programme was also completed by 43/86 (50%) patients undergoing C A B G in 1994. An analysis of the 117 M I patients who were discharged with a H e a r t M a n u a l in 1994 showed that the p r o p o r t i o n o f patients receiving a h o m e visit rose f r o m 24/64 (38%) in the first half of the year to 44/53 (83%) between July and D e c e m b e r 1994. The main cause of the improvement was that m o r e C o m m u n i t y Nurses h a d been trained to use the H e a r t Manual. The reasons why nine patients had not received a h o m e visit in the second half of the year were patient readmission (2), patient refusal (2) and no nurse trained (5). Since 1994, we have continued H e a r t M a n u a l training for C o m m u n i t y Nurses, so that every practice in the region now has access to a H e a r t Manual Facilitator. Thus, a vital link between the hospital and the c o m m u n i t y has been established.

DISCUSSION Despite its increasing popularity and much encouragement from the British Cardiac Society (Horgan et al 1992; T h o m p s o n et al 1996) and other expert groups (Bethell 1996), Cardiac Rehabilitation is still only provided to a minority of patients with coronary heart disease (CHD). A survey conducted in Scotland in April 1994 found that 69 programmes provided outpatient C R to 4980 patients, and inpatient C R to 8920 patients in the previous year. This represented 17% and 30% of patients admitted to hospital in Scotland with C H D (excluding heart failure) that year (Campbell et al 1996a). Moreover, the practice of C R varied widely between programmes: only 29% included sufficient exercise to be beneficial, only 25% gave education in a manner likely to produce the benefits reported in randomized trials, and only 5% used relaxation training correctly (Campbell et al 1996b). A similar survey with similar conclusions has been conducted in England (Davidson et al 1995). The findings of both surveys are mirrored by the results of the A S P I R E study (Action on Secondary Prevention through Intervention to Reduce Events), which showed quite clearly that across the U K in 1994 there

A model for cardiac rehabilitation in rural areas remained a considerable potential to reduce the risk of a further major ischaemic event in patients with established CHD (ASPIRE Steering Group 1996). Against this background, the Dumfries and Galloway CR programme was established in 1990. Initially, resource limitations and the fact that the area is predominantly rural with a widely dispersed population (148 000 people live in an area 100 miles across from Stranraer in the west to Langholm in the east) restricted our outpatient programme to patients who were capable of attending classes in Dumfries. In 1992, additional community-based classes were established in Newton Stewart and Sanquhar. However, this still left a significant part of the population with no access to community CR (Fig. 1). Starting in 1992, we began to use the Heart Manual for post-MI patients. Eighty community-based nurses, including District Nurses, Health Visitors and Practice Nurses, and 19 Coronary Care Nurses have since been trained as Heart Manual Facilitators. The attractions of using the Heart Manual in this way are that it helps alleviate the problem of providing CR to a rural population. It involves primary care staff who often have detailed knowledge of the family which is not readily available to the acute service and, from the patient's point of view, it provides continuity of care, with the same advice and plan for resuming activity being advocated both by the acute and primary care teams. Our audit of Heart Manual discharges (Table 2) has shown that this form of community CR works well in most parts of the region, though a number of concerns remain. We feel that some patients will be unable to benefit from what is essentially a self-help programme with minimal nursing support, while others who remain clinically anxious or depressed (Zigmond & Snaith 1983) may require formal psychological or psychiatric support (McGee & Thompson 1995). This is in addition to those who may benefit from further medical assessment (McMurray & Rankin 1994), leading to coronary angioplasty or CABG. Such considerations have led directly to the most recent development in our CR programme, starting in April 1996, which has been the appointment of a CR Outreach Sister (LLL), whose remit is to extend CR into rural areas and target those at highest risk. The creation of an Outreach Sister's post, the use of the follow-up form and the opening of three more community-based outpatient centres (making six in all) has allowed us to develop the four-stage model of CR advocated by a British Cardiac Society Working Party report on Cardiac Rehabilitation (Horgan et al 1992) and described in detail in the British Association for Cardiac Rehabilitation guidelines for CR (Stokes et al 1995). The present position is that a CR-trained nurse introduces each patient and their partner to the Heart Manual while in hospital. Patients are given a copy of their own discharge

143

record when they leave (Stage 1). During the next six weeks, they work through the Heart Manual under the supervision of a Heart Manual Facilitator, who will either visit them at home or telephone during the first week after discharge, and again during weeks 3 and 6. The CR Sisters are contactable by page and answerphone to advise and support Community Nurses during this period (Stage 2). At six weeks, the community-based Heart Manual Facilitator completes her section of the follow-up form and returns this to the Outreach Sister for information and action (Fig. 2). All patients under 70 years are referred automatically to a one-stop post MI assessment clinic run by our Cardiologists (SJC and GWT), as are those over 70 years identified by their Community Nurses as having recurrent pain or breathlessness. Similarly, patients who remain anxious or depressed as judged by their Hospital Anxiety Depression (HAD) score at six weeks and three months, are selected for referral to a psychiatrist. As a result both of our follow-up form and of securing six centres for outpatient CR, we are now in a position to extend CR into rural areas where followup has traditionally been poor, and to target patients with complex needs, in particular women (McGee & Horgan 1992), patients with angina (Todd & Ballantyne 1990) and heart failure (Coats 1993), patients with deprived backgrounds (Pellet al 1996) and the elderly (Hellman & Williams 1994). By doing so, we should answer the criticism that outpatient CR programmes (Stage 3 of the British Cardiac Society model) select only low-risk patients for whom the benefits of CR may be marginal (Mayou 1996). The fourth stage of CR concerns long-term followup. The emphasis here is on self-help and motivating long-term changes in behaviour, supervised by the Community Nurses. Many patients who have completed an exercise class have expressed a desire to continue group-exercise sessions and, in response to this demand, Hale and Hearty Clubs have been formed in Dumfries, Kirkcudbright, Sanquhar, Castle Douglas and Annan. These are self-help groups run by patients for patients, facilitated by our Outreach Sister with medical staff on call for emergencies. Most patients joining these clubs will have attended an exercise class but, if not, then we recommend an exercise test first. In summary, we believe that this innovatory model of care may answer a number of concerns that currently exist in CR. Not only should it facilitate the universal provision of CR across a large rural area, but also it will establish a system for assessing patients' needs and providing support tailored to those needs at a time when patients most require it, i.e. immediately after discharge from hospital and during the next six to twelve weeks. In particular, it should maximize our ability to help cardiac patients at highest risk and, by doing so, make the most efficient use of resources. If successful, then it is likely

144 Coronary Health Care that the knowledge gained in developing this scheme will be of interest to other CR programmes that provide support to a predominantly rural population. ACKNOWLEDGEMENTS : We would like to thank the British Heart Foundation, the Chest, Heart and Stroke Association, the Queen's Nursing Institute (Scotland), Merck Sharp and Dohme Limited and Dumfries and Galloway Health Board for funding this project; also Dr Graham Jackson, who gave us the idea of a patient-held discharge record and follow-up form, and Mrs Josephine Campbell for her help in the preparation of the manuscript. REFERENCES ASPIRE Steering Group 1996 A British Cardiac Society survey of the potential for the secondary prevention of coronary disease: ASPIRE (Action on Secondary Prevention through Intervention to Reduce Events). Principle results. Heart 75: 334-342 Bethell HJN 1996 Going home: the first few weeks after a heart attack. British Medical Journal 312:1372 Campbell NC, Grimshaw JM, Rawles JM, Ritchie LD 1996a Cardiac rehabilitation in Scotland: is current provision satisfactory? Journal of Public Health Medicine 18:478--480 Campbell NC, Grimshaw JM, Ritchie LD, Rawles JM 1996b Outpatient cardiac rehabilitation in Scotland: are the potential benefits being realised? Journal of the Royal College of Physicians of London 30:514-519 Chua TP, Lipkin DP 1993 Cardiac rehabilitation. British Medical Journal 306:731-732 Coats AJS 1993 Exercise rehabilitation in chronic heart failure. Journal of the American College of Cardiology 22 (supp A): 172a-177a .... Davidson C, Reval K, Chamberlain DA, Pentecost B, Parker J 1995 Report of a working group of the BCS: cardiac rehabifitation services in the United Kingdom 1992. British Heart Journal 73:201-202 Hellman EA, Wilfiams MA 1994 Out-patient cardiac rehabilitation in elderly patients. Heart and Lung 23:506-512 Horgan J, Bethell H, Carson Pet al 1992 British Cardiac Society Working Party Report on Cardiac Rehabilitation. British Heart Journal 67:412418

Jackson G 1995 Myocardial infarction. Update 15 November: 494-500 Jones DA, West R 1996 Psychological rehabilitation after myocardial infarction: multi centre randomiseA controlled trial. British Medical Journal 313:1517-1521 Lewin R, Robertson IH, Cay EL, Irving JB, Campbell M 1992 Effects of self help post myocardial infarction rehabilitation on psychological adjustment and use of health services. Lancet 339:1036-1040 Linden W, Stossel C, Maurice J 1996 Psychosocial interventions for patients with coronary artery disease. Archives of Internal Medicine 156:745-752 Mayou R 1996 Rehabilitation after heart attack. British Medical Journal 313:1498-1499 McGee HM, Horgan JH 1992 Cardiac rehabilitation programmes: are women less likely to attend? British Medical Journal 305: 283-284 McGee HM, Thompson DR 1995 Psychosocial aspects of cardiac rehabilitation. In: Coats AJS, McGee HM, Stokes HC, Thompson DR (eds) BACR Guidelines for Cardiac Rehabilitation. Blackwell Scientific, Oxford, pp 102-124 McMurray J, Rankin A 1994 Cardiology I: treatment of myocardial infarction, unstable angina and angina pectoris. British Medical Journal 309:1343-1350 O'Connor GT, Buring JE, Yusuf Set al 1989 An overview of randornised controlled trials of rehabilitation with exercise after myocardial infarction. Circulation 80:234-244 Oldridge NB, Guyatt GH, Fischer ME, Rimm AA 1988 Cardiac rehabilitation after myocardial infarction: combined experience of randomised clinical trials. Journal of the American Medical Association 260:945-950 Pell J, Pell A, Morrison C, Blatchford O, Dargie H 1996 Retrospective study of influence of deprivation on uptake of cardiac rehabilitation. British Medical Journal 313:267-268 Stokes H, Turner S, Farr A 1995 Cardiac rehabilitation: programme structure, content, management and administration. In: Coats AJC, McGee HM, Stokes HC, Thompson DR (eds) BACR Guidelines for Cardiac Rehabilitation. Blackwell Scientific, Oxford, pp 12-39 Thompson DR, Bowman GS, Kitson AL, de Bono DP, Hopkins A 1996 Cardiac rehabilitation in the United Kingdom: guidelines and audit standards. Heart 75:89-93 Todd IC, Ballantyne D 1990. Anti anginal efficacy of exercise testing. British Heart Journal 64:14-19 Zigmond AS, Snaith RP 1983 The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica 67:361-370