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Sonya Panchuk, Belinda Landry, and Jason Courchaine demonstrate how to move a patient recovering from heart surgeryResearch & Innovation
Cardiac care
A physiotherapist at St. Boniface Hospital has
played a key role in developing a new protocol
that promises to help heart patients recover
more quickly from surgery
Sonya Panchuk, Belinda Landry, and Jason Courchaine demonstrate how to move a patient recovering from heart surgery.
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By Sharon Chisvin
Summer 2018

Kelly Codispodi is well aware of the challenges patients face as they recover from heart surgery.

That's to be expected, considering the physiotherapist has spent the last 14 years helping patients at St. Boniface Hospital navigate the road to rehabilitation following their operations.

It is not surprising, then, that she would become more than a little intrigued when she started to notice that some of her patients appeared to recover from surgery faster than others.

The more she thought about it, the more she wondered: What could account for the differences in recovery time?

Eventually, the University of Manitoba graduate would find the answer to that question. In doing so, she would also play a leading role in the development of a new physiotherapy protocol for patients recovering from heart surgery, one that will help enable them to leave hospital sooner than they would otherwise.

The new protocol - called Moving Safely After Heart Surgery - is being introduced at St. Boniface Hospital over the summer. When fully implemented, it will lead to important changes in the day-to-day approach to in-patient, post-surgery recovery and rehabilitation by ensuring patient mobility is tailored to each person's capabilities.

As Codispodi explains, that has not always been the case.

Historically, post-cardiac surgery patients have been instructed to limit the use of their arms for six to eight weeks following their operation with the belief that this will reduce stress on the sternum (breastbone) to provide sufficient time to heal. In other words, patients were limited in activities that require pushing, pulling, lifting or carrying objects weighing more than 10 pounds. They were also unable to undertake any loadbearing activity, including supporting their own body weight while rising from a chair, for the duration of the healing process.

Despite these protocols, however, Codispodi and her colleagues noticed that patients frequently used their arms well before the six weeks had elapsed and never seemed to suffer any ill effects from doing so. This was particularly evident among patients who had arrived for surgery with pre-existing mobility issues, such as neuro-muscular disorders or amputations, which meant they had no option other than to use their arms in order to maintain their functional independence.

Photo of Kelly Codispodi
Kelly Codispodi's efforts demonstrate her commitment to improving patient care.

"There were patients that would need to stay in hospital for prolonged periods, often for several weeks, to allow their sternal precautions to be completed prior to them being able to use their arms to get up out of a chair," Codispodi says. "This seemed extreme, especially when we would notice some patients using their arms despite being provided instructions not to do so, with no adverse effects."

So, in 2015, together with her colleague Sonya Panchuk, Codispodi decided to research whether there was any evidence to support the post-surgery cardiac restrictions.

"I called across Canada and spoke to physiotherapists in the other main cardiac surgery centres to ask about their sternal precautions," Codispodi recalls. "The common theme was that we all felt the current precautions were too restrictive and not well supported, but there was nothing yet tried to suggest it was safe to make a change."

Then, in the winter of 2017, Codispodi came across an online article co-authored by Dr. Jenny Adams, of Baylor University Medical Centre, that supported her department's observations and also suggested an alternative approach to the customary sternal precautions.

That alternative approach is based on basic kinesiology movement principles, best practice models and patient tolerance levels. Significantly, it recognizes that every patient is different and that every patient's capability, pain threshold and rehabilitative progress are different as well. The result is a more patient-centred approach to care, one that involves removing pre-determined timelines or weight restrictions, and ensures that patients are treated as individuals.

Codispodi subsequently sought to modify the Baylor team's work for St. Boniface Hospital.

As she explains, any effort to modify patient care must begin by engaging the entire health-care team, something that comes naturally at St. Boniface.

"The Rehabilitation Services Department encourages evidence-based practice, which allows us to investigate alternatives for our cardiac surgery population," Codispodi says. "The team collaboration and respect that happens on a daily basis within the cardiac surgery program made it easy to approach the physicians and leadership with this initiative."

After leading the development of a revised care plan for post-operative cardiac surgery patients, Codispodi worked with Dr. Rakesh Arora, Medical Director of Cardiac Surgery and Cardiac Surgery Critical Care at St. Boniface, to proceed with implementing the changes.

While St. Boniface has embraced the "concepts" of early mobilization after cardiac surgery, Arora says the work carried out by Codispodi and Panchuk indicated that more could be done.

"Kelly brought important new information that challenged us to question our paradigm of care," Arora explains. "Our methods, which are the same as almost every other cardiac surgery centre, were more restrictive than is likely needed. These old methods were based more on tradition than on sound physiology and science, and what may have been appropriate decades ago has since changed."

Arora says the development of the new approach to care underscores the dedication of health-care providers at St. Boniface and the culture the hospital has created.

"Kelly has tried to bring us up to the level where we can be leaders in enhancing people's recovery after surgery," says Arora, who is also professor and Head of Cardiac Surgery in the Department of Surgery at the Max Rady College of Medicine at the University of Manitoba.

"We are very fortunate to have fantastic people such as Kelly involved with the care of our patients. She has done the research, created content, made presentations, and recruited a multidisciplinary working group of nurses, physiotherapists, occupational therapists, physician assistants, health-care aides, residents and surgeons. Together, without any external funding, they have developed a sustainable process that already extends beyond the rehabilitation department to the wards, and beyond the hospital to out-patient cardiac rehab programs, as well as the College of Rehabilitation Sciences. And, she has performed all of this work largely with sweat equity, driven by the intrinsic need to improve patient care," he says.

"I believe that it is a great testament to the culture that we have been able to develop in the cardiac surgery program over the past 14 years, that team members feel empowered to drive important initiatives such as this to improve the perioperative experience and improve value for our patients."

Arora says that with the new protocol, it is expected that certain patients will be able to recover more quickly and improve their quality of life sooner. However, those who need more time to recover will get it. "The intent is to tailor the care to the patient's ability," he says. "It will get people moving and using their muscles quicker to prevent further deconditioning. We hope that this will allow them to get out of hospital and allow them to get back to their desired activities of daily living sooner."

To ensure that the new approach is both effective and meeting the needs of the patients, the surgical and rehabilitative teams will closely assess the new protocol roll-out via patient surveys and diagnostic testing. To gain information on patient reported outcomes, data regarding patient satisfaction and attitudes, pain and breathing levels, length of hospital stays, and rates of re-hospitalization are all being compiled and compared. Preliminary results regarding the impact of the new protocol will be published in the spring of 2019.

Even as these comparisons are being made, Arora expects that the new rehabilitative protocol will be applied to all post-cardiac surgery patients at St. Boniface. On average, he says, the hospital completes more than 1,000 cardiac surgical procedures every year. He also expects that the new protocol will help further reinforce the hospital's position as a national and international leader in post-cardiac surgery care.

Photo of nurse educators Sandy Warren and Belinda Landry
Nurse educators Sandy Warren (left), and Belinda Landry are helping the rehabilitation staff roll out the new protocol for patients recovering from heart surgery at St. Boniface Hospital.

Improving patient care has always been one of St. Boniface Hospital's primary objectives, and it is a goal that it meets and exceeds on a regular basis.

"If you look at outcomes after cardiac surgeries," Arora says, "we have some of best results in Canada, if not the best, particularly regarding how patients do after surgery in hospital and how they do after returning home."

That success, of course, is due to many factors and a great number of highly skilled and committed health-care practitioners. But the open, supportive and stimulating atmosphere that prevails in St. Boniface's corridors also plays a key role in the institution's success.

It is this collaborative and respectful atmosphere, after all, that made it possible for Codispodi and her rehabilitation team to openly question the standard protocol, and search out and develop a better alternative.

It is this atmosphere, Arora adds, that helps ensure that patients at St. Boniface don't just survive, but thrive after their surgery.

Sharon Chisvin is a Winnipeg writer.