RESEARCH PAPER

Concordance with phase‑one cardiac rehabilitation

guidelines in the inpatient setting

Authors Abstract

Objective
Maria C Murphy
To examine concordance with phase‑one cardiac
RN, PhD candidate
rehabilitation (CR) guidelines, undertake an
Lecturer, LaTrobe University/Austin Health Clinical
intervention that might optimise adherence to the
School, Clinical Nurse Specialist, Austin Health,
guidelines, and establish a benchmark for practice in
Melbourne, Australia
the coronary care unit (CCU) setting.
maria.murphy@austin.org.au
Design
Marcia V George Pre‑post intervention medical record review.
RN, RM, DN
Setting
Adjunct Professor of Nursing and Midwifery, RMIT
Level 1, university affiliated coronary care unit (CCU),
University. Nurse Unit Manager, Coronary Care Unit,
Melbourne, Australia.
Austin Health, Melbourne, Australia
Subjects
Andrea L Driscoll Inpatients of the CCU with a discharge diagnosis of
RN, PhD candidate acute coronary syndrome, ischaemic‑induced acute
Deakin University, Cardiology Research Fellow, Austin pulmonary oedema, myocardial infarction, arrhythmia,
Health, Melbourne, Australia or cardiac arrest, and patients for elective coronary
interventions (eg. angioplasty).
Interventions
Key Words Medical record review of concordance with phase‑one
CR guidelines and staff in‑services to communicate the
heart disease, rehabilitation, adherence, standards results; distribution of a questionnaire post in‑service
to collate staff perceptions of barriers to undertaking
phase‑one CR; and repeated medical chart audit to
re‑assess concordance.
Main outcome measures
Concordance with the guidelines for phase‑one CR.
Results
Data was complete for 89 cases. Concordance rates
ranged from 5 to 100%. Good concordance with
guidelines was recorded in advising the patient of their
medical diagnosis (98‑100%); and in assessing the
patient and their family’s psychological adjustment
to their condition and the impact it had on their well
being (80‑83%). The only significant improvement post
intervention was a written invitation to a phase two CR
program (5 vs. 14%).
Conclusions
The audit raised awareness of barriers to undertaking
phase‑one CR but did not appreciably alter the
concordance rates. This suggests other strategies and
resources to increase the delivery of phase‑one CR
need to be considered

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INTRODUCTION This study centre recorded 1278 inpatient

admissions to their coronary care unit (CCU) in
Heart disease is the primary cause of disease burden
2005. Despite the large number of admissions to
(AIHW 2003) and the most common cause of sudden
the CCU and the recognition of coronary disease as
death in adult Australians ( AIHW 2005; AIHW and
a condition that requires long term care and patient
NHF of Australia 2004). Effective evidenced based
education, this was the first attempt to evaluate
guidelines exist for the inpatient management of
concordance with phase‑one CR guidelines. At
acute cardiac events (NHF/CSANZ 2007). Evidenced
the time of conducting this study there were few
based care has reduced the mortality rates of
published reviews of adherence to phase‑one
patients, who can then proceed to discharge from
CR guidelines in the clinical setting. There were
hospital following an acute cardiac event and
some reports in the literature that adherence to
intervention. Prior to hospital discharge, patients
guidelines that inform practice for the management of
and their families require education and access
cardiovascular health conditions were sub‑optimal. A
to information on secondary prevention strategies
recent study of quality of care for patients with acute
that will empower them to make the necessary
coronary care syndromes published the outcomes
lifestyle modifications to actively manage a chronic
from 12 process of care quality indicators (Scott et
health condition such as heart disease (Flynn et al
al 2002). Concordance with recommendations for
2007).
inpatient cardiac rehabilitation was reported as 47%
National and international guidelines recommend and 7% for phase‑two cardiac rehabilitation. These
attendance at a cardiac rehabilitation (CR) program authors suggested that quality improvement might
for patients post myocardial infarction (Leon et al follow from the implementation of a guideline‑linked
2005; NHF/ACRA 2004). Indeed, all acute care audit and feedback process, professional education,
cardiac patients require cardiac rehabilitation and care maps, or from a combined educational
access to secondary prevention programs (Goble and approach.
Worchester 1999). The National Heart Foundation
In a more recent study (Harvey et al 2005), adherence
of Australia and the World Health Organization
to the evidence‑based guidelines for the inpatient
recommend that CR services be available and
management of chronic obstructive pulmonary
routinely offered to everyone with cardiovascular
disease (COPD) was less than 60% and referral to an
disease and that the program be delivered by qualified
outpatient‑based pulmonary rehabilitation program
health clinicians (NHF/ACRA 2004; WHO 1993).
was 15%. These authors conducted an audit review
Cardiac rehabilitation is the process through which and results were reported back at a senior clinical
patients return to an active and satisfying lifestyle group peer review meeting. Following the feedback
and provision of this service is an expected tenet in of the audit results, a second audit failed to report
the patient care continuum (ACRA 1999). Phase‑one significant increases in adherence to the guidelines.
CR is primarily concerned with counselling. It This outcome suggested that while professional
aims to explain the diagnosis and to raise the education and feedback improved concordance with
candidate’s awareness of risk factor modification, some of the guidelines, additional mechanisms such
cardio‑protective dietary guidelines, smoking as identifying barriers to adherence should also be
cessation, and early mobilisation. It includes examined to facilitate optimal uptake of guidelines
reassurance of progress, family involvement, and in clinical practice.
education relating to angina, medications, alcohol
Phase‑one CR is often regarded as an automatic part
consumption, and return to work and/or driving. It
of cardiac inpatient care (Day and Batten 2006).
further includes follow‑up and referral to a phase two
Despite the evidence to support cardiac rehabilitation
program (Goble and Worchester 1999; New Zealand
it has been suggested that a disparity often exists
Guidelines Group 2002, 2003).

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 RESEARCH PAPER

between the published guidelines of care and actual cases were accepted for the audit if the patient’s
practice in the clinical setting (Flynn et al 2007). The medical file was available to be reviewed and if it
primary aim of this investigation was to examine confirmed the discharge diagnosis of a cardiac event
concordance to phase‑one CR guidelines. The study’s as the primary reason for admission to the CCU. Cases
further aim was to undertake a simple intervention were excluded if the medical record reported that
that might optimise adherence to phase‑one the patient had a co‑existing terminal illness or had
guidelines and establish a benchmark for translating cognitive impairment. Terminal illness or cognition are
evidence into practice in the CCU setting. not reasons for exclusion from the CCU, but asking
such candidates how they could modify their cardiac
METHOD risk factors would seem inappropriate.
Study design and setting Data Collection
A retrospective chart review was conducted in a level A trained abstractor extracted the information from
one university‑affiliated hospital. The underlying the hospital records using a standardised data
premise of this study was that if phase‑one CR was collection tool. The tool was based predominately
not documented in the patient’s medical records on the content of the New Zealand Guidelines
then it had not been done. Group’s evidence‑based guidelines (New Zealand
There were two data collection periods. The medical Guidelines Group 2002). These guidelines report
records of the first fifty admissions to the CCU in the level of evidence with each component that
one calendar month were audited. A further fifty cardiac rehabilitation education seeks to cover.
consecutive admissions to the CCU were audited Recommendations from these guidelines were
following two staff in‑services of the primary audit’s cross‑checked with other published reports
outcomes, and completion of an anonymous (NHF/ACRA 2004; NHF/CSANZ 2004; Goble and
questionnaire by the CCU staff. The questionnaire Worchester 1999) before the data collection tool
outlined commonly perceived barriers to undertaking was finalised. These locally produced publications
phase‑one CR education and invited participants ensured that the guidelines espoused were relevant
to document any other barriers not listed. Both to the local population. A synthesis of these
in‑services were conducted during the overlap time guidelines as the basis for the audit tool ensured
between the morning and evening shifts. the ‘best available evidence’ was incorporated in
the development of the tool as summarised in Table
As this was a pilot study, the sample size for the
two. The audit tool is available for scrutiny and/or
audit was chosen arbitrarily. The hospital’s ethics
use from the corresponding author.
committee granted approval for this quality assurance
activity and for the reporting of the outcomes. Intervention
Data from the first audit were analysed and the
Subjects
outcomes twice presented at the CCU’s monthly
Eligible subjects were consecutive patients
staff meetings. Staff discussed the outcomes and
admitted to the CCU with a discharge diagnosis
completed an anonymous questionnaire of perceived
of acute coronary syndrome, ischaemic‑induced
barriers to implementing phase‑one cardiac
acute pulmonary oedema, myocardial infarction,
rehabilitation. Questionnaires were deposited in a
arrhythmia, or cardiac arrest, and patients for
box and the feedback summarised.
elective coronary interventions (eg. angioplasty).
All admissions were recorded in the CCU patient Statistical analysis
admissions register. The admissions register is Patient characteristics and demographics were
derived from the Australian Nursing Assessment and compared between groups using х2, parametric
Documentation Alternative (ANADA) system which (t‑test), and non‑parametric methods. A p‑value
has been reported previously (George 1995). The less than 0.05 was considered to be statistically

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Table 1: Patient characteristics for the pre and post intervention audit results

Pre‑ Intervention Post‑ Intervention p

n = 40 n = 49 value
Age: M (SD) years 66 (15) 63 (14) 0.39
Gender: (Male) 20 (50%) 34 (70%) 0.09
LOS in CCU: M (SD) days 4 (4) 2 (2) 0.01*
Cumulative LOS in hospital: M (SD) days 6 (6) 4 (3) 0.05
Discharged home directly from the CCU 37 (93%) 42 (86%) 0.34
Australian born 19 (48%) 23 (47%) 0.94
AMI (STEMI / NSTEMI) 20 (50%) 15 (31%) 0.34
Elective percutaneous coronary intervention 5 (13%) 17 (35%) 0.01*

Note: M: Mean; SD: Standard Deviation; LOS: Length of stay, * Significant difference

significant. Kolmogorov‑Smirnov and Shapiro‑Wilks the intervention. Statistical analysis was performed
tests were performed to assess normality of the using SPPS version 13.0 (Ill, USA).
data. If the p‑value was <0.05 in either test, it was
assumed the data was not normally distributed. FINDINGS
Concordance rates for each item were calculated as There were statistically significant differences
the number of phase‑one components documented between groups in the patient’s length of stay in
in audited records divided by the number in the audit CCU (p=0.01) despite no significant differences
sample and expressed as a percentage. Ninety five between groups in age, gender, country of origin, or
per cent confidence intervals were calculated for proportion of direct discharges from the CCU. There
the difference in concordance rates before and after were no significant differences between the pre‑ and

Table 2: Comparison of concordance for each phase‑one recommendation pre‑ and post‑intervention audits

Pre‑ Intervention Post‑ Intervention 95% CI for the

% concordance % concordance difference in
(n = 40) (n = 49) concordance rates
Cardiac diagnosis 100 98 2 (‑0.76, 0.26)
Cardiac risk factors 78 71 7 (‑0.14, 0.11)
Nutritional advice 40 35 5 (‑0.07, 0.38)
Smoking cessation referral or record of smoking
status 68 67 1 (‑0.13, 0.61)
Physical activity plan until attendance at phase
two cardiac rehabilitation 60 43 17 (‑0.06, 0.47)
Psychological aspects and relationships 83 80 3 (‑2.87, 0.78)
Involvement of partner and family in education 68 55 13 (‑0.10, 0.31)
Angina management plan 68 59 9 (0.02, 0.41)*
Education about medications 73 78 5 (‑0.01, 0.27)
Healthy heart range for alcohol consumption 5 6 1 (‑0.07, 0.38)
Return to work 15 20 5 (‑0.22, 0.53)
Return to driving 13 4 9 (0.05, 0.71)*
Written invitation whilst inpatient to attend
phase‑two cardiac rehabilitation 5 14 9 (‑0.19, 0.15)

Note: *confidence interval (CI) does not include zero statistically significant difference.

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post‑intervention audits in patients presenting with approximately half the CCU roster. In‑services were
an acute myocardial infarction (AMI). The volume of not conducted on the night shift and rotating rosters
elective percutaneous coronary procedures differed meant that it would be difficult to have all staff attend
significantly (p=0.01), which most likely explains the these inservice meetings.
reduced length of stay in CCU and in hospital (see
Patients from both of the audit periods who during
table 1).
their admission to the CCU were transferred out to the
Table 2 summarises the adherence to the phase‑one ward prior to their discharge home had their charts
CR guidelines pre and post intervention. Concordance reviewed to determine the degree of phase‑one CR
with the guidelines remained exceptionally good that had occurred whilst they were recovering in the
in documenting the patient’s medical diagnosis, ward environment (see table 4).
discussing with the patient their cardiac risk factors,
Table 4: Documented phase‑one CR conducted with
psychological adjustment to illness/ roles and
the patient upon transfer to the ward from the CCU
relationships, and discussing with the patient the use
of medications for their health management. Patient First Second
audit audit
education regarding their prescribed medication, n=16 n=12
expected time off work, alcohol consumption and Cardiac diagnosis discussed
a written invitation to attend phase two cardiac with patient 1% 25%
rehabilitation were documented to have occurred Cardiac risk factors
discussed with patient 0% 17%
more frequently post‑intervention but these increases
Angina management plan
did not reach statistical significance. There were
discussed with patient 1% 42%
no statistically significant improvements recorded
between the audit groups in the advising of patients DISCUSSION
of a cardio‑protective dietary intake (p=0.18) or in the
In the USA, it has been reported that 18% of men
recording of smoking status/referral to the hospital’s
and 35% of women experience a further myocardial
smoking cessation clinic (p=0.20). Formulation of a
infarction within the following six year period
physical activity plan during phase‑one CR, education
subsequent to their initial coronary event (American
on the use of sublingual glyceryl‑trinitrate (‘Anginine’)
Heart Association as reported in Flynn et al 2007).
and on resumption of driving were recorded to have
The likelihood of repeated presentations provides
occurred less in the second audit.
an additional impetus to empower patients and
Table 3: Barriers to phase‑one cardiac rehabilitation their families with evidenced based information
In the CCU setting and access to resources to help delay progression
Rank in coronary heart disease.
Busy shift, education not a priority 1 Our audit quantified the percentage of CCU patients
Use of itinerant (locum) staff 2 who had received documented phase‑one CR
Junior/ new staff 3 education in a given sample. Good concordance
Patient too tired or anxious 4 with the phase‑one CR guidelines were recorded
Delay in confirmation of the medical in advising the patient of their medical diagnosis
diagnosis 5
(98‑100%), in assessing the patient and their
The barriers that staff identified that had prevented family’s psychological adjustment to their condition
phase‑one cardiac rehabilitation from occurring in and the impact it had on their personal and social
the CCU have been summarised in table 3. All staff well‑being (80‑83%). The reporting back of the first
present at the two clinical meetings (n=18) completed audit results enabled some staff to ask what and
the questionnaire. This response rate represents where the phase‑one CR guidelines contained and

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could be accessed. In addition, the CCU staff had the with the outpatient follow up and maintenance
opportunity to rank in their opinion the barriers to services. This need for time and resources to be
implementing phase‑one CR in the CCU. In evidenced invested in phase‑one CR education in the CCU
based projects, clinician input enables a greater link setting is especially evident when all patients in both
between the unit’s and the clinician’s priorities and audit periods who were transferred out to the ward
to explore gaps in professional standards of care appeared to receive minimal phase‑one CR education
(Newhouse et al 2005). in that setting. Unfortunately, education does not
appear on any budget and is generally considered
The pressure of time was the primary barrier, followed
a generic responsibility for all health disciplines.
by the staffing profile in the unit, patient fatigue, and
However as health education is not ‘owned’ by any
the diagnostic ambivalence as evidenced with some
discipline or department nor has a discrete budget,
cardiac enzyme markers that delays confirmation
its central role in health management is often not
of a medical diagnosis. The presentation of the
given the priority it requires (Lorig 1995). Despite this
pre‑intervention audit outcomes and increased
anomaly, it is widely acknowledged that patients, staff
awareness of barriers was considered a possible
and the hospital all benefit when guideline based
strategy that would improve the documenting of
practiced is adhered to (Flynn et al 2007).
advice that patients received. With the exception of
issuing a written invitation to attend phase two CR The limitations of this audit included no customer
(5% vs. 14%), this study was unable to produce any feedback as to the quality of the information
significant improvements in the post intervention received, nor the likelihood of incorporation of
audit. This was an unexpected finding as a systematic the lifestyle modifications to optimise their health.
checklist of phase‑one CR and care maps exist in the The need to evaluate the quality of the phase‑one
CCU to optimise clinical practice. It has been identified cardiac rehabilitation program from the consumer
in the literature that barriers to guideline adherence perspective has been considered by other health
amongst physicians include a lack of awareness with services as an outstanding area yet to be fully
guidelines and a lack of time and resources (Cabana, examined (Stokes 1999). Other limitations of this
Rand and Powe 1999). The barriers reported by the study include the lack of random sampling, small
CCU nursing staff were aligned with these reported sample size and possible bias of the staff involved
barriers despite the systematic processes the CCU in the delivery of the phase‑one CR program.
had in place.
The underlying premise of the study was that if
There was a statistically significant reduced length phase‑one CR was not documented in the patient’s
of stay recorded in the CCU in the second audit medical records then it had not been done. These
time period, which would account for the reduced results are therefore a conservative estimate in
time patients had in CCU for education. The lack of a convenience sample of the number of cardiac
significant improvement in the second audit was patients who received phase‑one CR in the inpatient
interesting as there were a significantly greater setting.
number of elective CCU patients in this sample who
could be regarded as being in better prognostic shape CONCLUSION
and more likely to be earmarked for phase‑one CR This audit demonstrates the need to improve the
education. The high discharge rate (83‑96%) directly management of phase‑one cardiac rehabilitation
from the CCU to the patient’s home is indicative of the education in the inpatient setting. A benchmarking
need for phase‑one CR to be completed in the CCU. process that will allow ongoing evaluation of the
The patient’s hospital stay is the opportunity to outline evidenced‑based guidelines has been established.
the link between the inpatient cardiac care received The next step in our quality improvement process is

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to the modify barriers to implementing phase‑one CR Day, W. and Batten, L. 2006. Cardiac rehabilitation for women:
one size does not fit all. Australian Journal of Advanced Nursing,
education, and evaluate the participant’s feedback 24(1):21‑26.
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offered. 2007. Improving outcomes for acute coronary syndrome patients
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Victorian Government Department of Human Services.
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