Cardiac Rehabilitation: the four phase process

How the service is delivered at the Royal Sussex County Hospital
The process runs from admission to discharge, including the referral process: There are four phases of Cardiac Rehabilitation:

• Phase 1: In-Patient phase
• Phase 2: Immediate post discharge rehabilitation
• Phase 3: Outpatient rehabilitation
• Phase 4: Long term maintenance of changed behaviour
  

Phase 1 (In-Patient phase)
During this in-hospital phase, a Cardiac Rehabilitation Nurse sees each patient and an individual assessment is carried out to assess risk factors and provide an individual plan for discharge, as per government guidelines. The issues we consider for in-patient needs include:

• Reassurance
• Information, both verbal and written
• Risk factor assessment
• Education of patients and carers
• Mobilisation and discharge planning
• Current cardiac condition
• Current drug therapies
• Previous medical history

The government guidelines state that every hospital should ensure that more than 85% of people discharged from hospital with a primary diagnosis of heart attack or after bypass surgery or angioplasty & stent insertion are offered cardiac rehabilitation; a recent audit of this milestone at the Royal Sussex County Hospital showed that the Cardiac Rehabilitation team exceeded this with 95% of eligible patients being offered the service.

Phase 2 (Immediate Post-Discharge rehabilitation)

		During Phase 2, the goals set in Phase 1 are reviewed and other members of the multi-disciplinary team (see below) are employed as necessary to achieve them. The Cardiac Rehabilitation team at this Trust achieves Phase 2 by providing a telephone follow up service. The Cardiac Rehabilitation nurses refer patients to the physiotherapist for a exercise capacity assessment prior to commencement of the Phase 3 exercise programme which follows. The government guidelines set the following targets in relation to Phase 2... Comprehensive assessment of cardiac risk, including physical, psychological and social needs for cardiac rehabilitation; and a review of the initial plan for meeting those needs.

The government guidelines set the following targets in relation to Phase 2...

Comprehensive assessment of cardiac risk, including physical, psychological and social needs for cardiac rehabilitation; and a review of the initial plan for meeting those needs.

Phase 3 (Out-Patient Rehabilitation)

    
This is a six week course led jointly by the Cardiac Rehabilitation Nurses and the Cardiac Rehabilitation Physiotherapists. It runs for 2 hours twice a week, so patients are invited to attend for 12 sessions in total. In respect of patient choice, there are 3 programmes to choose from, one at the Latilla gym in the hospital and two at the Moulscoomb Leisure Centre.

This phase consists of exercise-based training and educational input from the multi-disciplinary team. It usually begins within 3-4 weeks post-discharge for Heart Attack patients, two weeks post-discharge for patients following angioplasty & stent insertion and six weeks post-discharge for cardiac surgery patients.

Prior to their commencement of the programme, a physiotherapist assesses each patient in line with standards for the exercise component of Phase 3, and they are graded according to their functional capacity. Following this assessment the patients attend an induction session and then start the programme.

Prior to the start of each exercise session, each patient is individually assessed by a Cardiac Rehabilitation nurse taking in to account any ongoing symptoms, changes in vital signs and changes to medications. The Cardiac Rehabilitation nurses work jointly with the physiotherapists to provide supervision during exercise and take action as necessary if patients report chest pain, breathlessness or any other symptoms.

Using a high degree of clinical expertise the rehabilitation nurses refer back to consultant cardiologists, cardiac surgeons or patients' General Practitioners, depending on symptoms and risk stratification. This facilitates early intervention which could reduce risk of readmission into hospital. The Cardiac Rehabilitation nurses use validated tools to assess perceived exertion during exercise and target heart rate using heart monitors.

The multi-disciplinary team is involved throughout Phase 3 with input (1hr. every six weeks). Other sessions, including anatomy & physiology of the heart, the importance of exercise and secondary prevention are led by members of the Cardiac Rehabilitation Team.

The Phase 3 programme is an ideal chance for you to maximise your exercise capability, gain confidence and to attend talks about staying healthy. Our aim is to cater for all ages and abilities and to give patients the opportunity to meet other people who have been through a similar experience. The Phase 3 programme is funded by the hospital as part of your ongoing care.

The following are quotes from patients who have experienced all three phases of the service at the Royal Sussex County Hospital (quotes are taken from a patient satisfaction questionnaire):
"It has been a confidence boosting service, offering good support in both nursing and physiotherapy - can't see ways for improvement"
"An excellent programme - without exaggeration I can say that I feel a lot fitter and happier with my condition - even from the first session. I have in fact lost 7lbs from my original weight of 13st. The staff were really top quality in their attention to everybody (as individuals) always cheerful & friendly. I shall be signing on at Hove for Phase 4 - thanks to you all".
The cardiac rehabilitation service also provides a helpline for patients and carers; if we are not available to take your call leave a message on the answer phone and we will get back to you during working hours, which are between 09.00 and 17.00, Monday to Fridays. In an Emergency, please dial 999.

Phase 4 (Long-term Maintenance of Changed Behaviour)
Upon successful completion of Phase 3, patients are referred to Phase 4 programmes. These are community-based exercise programmes providing long term maintenance of changed behaviour.

The Cardiac Rehabilitation Team have been instrumental in providing supervision to applicants undertaking the Phase 4 B.A.C.R. course and as a consequence we can now offer more choice to our patients on discharge from Phase 3.

We have five programmes to choose from, the 'Take Heart Group' which is a patient-run support group based at Stanley Deason Leisure Centre, which provides long term maintenance of exercise and group support for patients with cardiac problems. The other four exercise programmes are based at a gym in Hove and the David Lloyd Centre in the Brighton Marina. These are all funded at a subsidised rate.

Phase 4 is vital if patients are to gain long term benefits, since habitual exercise over months and years is likely to contribute to a reduction in the progression of any underlying coronary disease.

People who can use the service
Brighton and Hove City Primary Care Trust patients admitted to the Royal Sussex County Hospital or the Princess Royal Hospital in Haywards Heath, following Myocardial Infarction (Heart Attack), Coronary Artery Bypass Surgery, Valve Surgery, Internal Cardioverter Defibrillator and Angioplasty & Stent insertion. We also see patients from the District General Hospitals along the south coast at RSCH. The service is available to all patients over 18yrs.