MOVING RIGHT ALONG: INCORPORATING PATIENT-SPECIFIC RISK FACTORS IN POST-CARDIAC SURGERY STERNAL PRECAUTIONS PRESCRIPTIONS

Abstract

Background/PurposeThe past 15 years of post-operative cardiac surgery patient recovery determined that traditional sternal precautions (SP) following a median sternotomy could lead to prolonged patient hospital admissions, increased patient physical deconditioning and subsequent loss of mobility with the lack of return to baseline functional status. Current evidence supports a less restrictive and more malleable approach to SP: a process that is modern and innovative rather than following historically arbitrated methods that are more restrictive than precautionary.Methods/ResultsOur tertiary care institution has developed an algorithm, based on best practice standards, that guides the selection of patients that would be candidates for modified SP in the post-operative cardiac surgery patient. Pre-operatively, the surgeon identifies patients primary and/or secondary risk factors; thus, enrolling the patient in standard or modified SP program. The algorithm, based on individual patient risk factors (body habitus, diabetes, cognitive status, smoking, intra-operative complications, surgical specificity and bone density) and clinical status of recovery, will guide the post-operative SP prescription. Patients deemed to be low risk for complications are prescribed modified SP for a six-week duration post-surgery date: no pushing, no pulling, no lifting more than 20lbs with their arms (provided their arms remain close to their body) while encouraging full shoulder and scapular range of motion. The high-risk patient population is prescribed an eight-week standard SP: no pushing, no pulling, no lifting more than 10lbs with their arms while engaging in pain-free shoulder and no scapular retraction past neutral. Should patients have no healing complications, they can resume unrestricted movements: low risk patients six weeks post-operatively and high-risk patients eight weeks post-operatively.Conclusion/Implications for PracticeSince this change in practice, there has been a demonstrated decrease in post-operative hospital length of stay, as well as a decrease in post-operative functional discharge prescriptions for ambulatory aids. Modified SP patients, requiring in-patient rehabilitation programs, have been more favorably accepted for admission due to a decrease in physical mobility restrictions, permitting an earlier return to functional baseline. Early data suggest the development of this algorithm initiates prompt physical recovery; demonstrates an increase in patient and caregiver(s) satisfaction; and eases the quality-of-life during the post-operative cardiac surgery phase of care, thus permitting an earlier initiation and compliance to the cardiac rehabilitation journey. Background/PurposeThe past 15 years of post-operative cardiac surgery patient recovery determined that traditional sternal precautions (SP) following a median sternotomy could lead to prolonged patient hospital admissions, increased patient physical deconditioning and subsequent loss of mobility with the lack of return to baseline functional status. Current evidence supports a less restrictive and more malleable approach to SP: a process that is modern and innovative rather than following historically arbitrated methods that are more restrictive than precautionary. The past 15 years of post-operative cardiac surgery patient recovery determined that traditional sternal precautions (SP) following a median sternotomy could lead to prolonged patient hospital admissions, increased patient physical deconditioning and subsequent loss of mobility with the lack of return to baseline functional status. Current evidence supports a less restrictive and more malleable approach to SP: a process that is modern and innovative rather than following historically arbitrated methods that are more restrictive than precautionary. Methods/ResultsOur tertiary care institution has developed an algorithm, based on best practice standards, that guides the selection of patients that would be candidates for modified SP in the post-operative cardiac surgery patient. Pre-operatively, the surgeon identifies patients primary and/or secondary risk factors; thus, enrolling the patient in standard or modified SP program. The algorithm, based on individual patient risk factors (body habitus, diabetes, cognitive status, smoking, intra-operative complications, surgical specificity and bone density) and clinical status of recovery, will guide the post-operative SP prescription. Patients deemed to be low risk for complications are prescribed modified SP for a six-week duration post-surgery date: no pushing, no pulling, no lifting more than 20lbs with their arms (provided their arms remain close to their body) while encouraging full shoulder and scapular range of motion. The high-risk patient population is prescribed an eight-week standard SP: no pushing, no pulling, no lifting more than 10lbs with their arms while engaging in pain-free shoulder and no scapular retraction past neutral. Should patients have no healing complications, they can resume unrestricted movements: low risk patients six weeks post-operatively and high-risk patients eight weeks post-operatively. Our tertiary care institution has developed an algorithm, based on best practice standards, that guides the selection of patients that would be candidates for modified SP in the post-operative cardiac surgery patient. Pre-operatively, the surgeon identifies patients primary and/or secondary risk factors; thus, enrolling the patient in standard or modified SP program. The algorithm, based on individual patient risk factors (body habitus, diabetes, cognitive status, smoking, intra-operative complications, surgical specificity and bone density) and clinical status of recovery, will guide the post-operative SP prescription. Patients deemed to be low risk for complications are prescribed modified SP for a six-week duration post-surgery date: no pushing, no pulling, no lifting more than 20lbs with their arms (provided their arms remain close to their body) while encouraging full shoulder and scapular range of motion. The high-risk patient population is prescribed an eight-week standard SP: no pushing, no pulling, no lifting more than 10lbs with their arms while engaging in pain-free shoulder and no scapular retraction past neutral. Should patients have no healing complications, they can resume unrestricted movements: low risk patients six weeks post-operatively and high-risk patients eight weeks post-operatively. Conclusion/Implications for PracticeSince this change in practice, there has been a demonstrated decrease in post-operative hospital length of stay, as well as a decrease in post-operative functional discharge prescriptions for ambulatory aids. Modified SP patients, requiring in-patient rehabilitation programs, have been more favorably accepted for admission due to a decrease in physical mobility restrictions, permitting an earlier return to functional baseline. Early data suggest the development of this algorithm initiates prompt physical recovery; demonstrates an increase in patient and caregiver(s) satisfaction; and eases the quality-of-life during the post-operative cardiac surgery phase of care, thus permitting an earlier initiation and compliance to the cardiac rehabilitation journey. Since this change in practice, there has been a demonstrated decrease in post-operative hospital length of stay, as well as a decrease in post-operative functional discharge prescriptions for ambulatory aids. Modified SP patients, requiring in-patient rehabilitation programs, have been more favorably accepted for admission due to a decrease in physical mobility restrictions, permitting an earlier return to functional baseline. Early data suggest the development of this algorithm initiates prompt physical recovery; demonstrates an increase in patient and caregiver(s) satisfaction; and eases the quality-of-life during the post-operative cardiac surgery phase of care, thus permitting an earlier initiation and compliance to the cardiac rehabilitation journey.