الفهرس 
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Abstract
Acute phase CR starts while the patient is still hospitalized and stabilized in hemodynamic conditions. Acute phase CR includes a combination of medical assessment, risk factor modifications, nutritional counseling, psychosocial interventions, early progressive physical activities to resume ADL and basic self-care after discharge from the hospital. Active and early engagement in acute phase CR improve cardiac health, functional status, alleviate activity related symptoms, improve uptake of other phases of CR and prevent reinfarction, morbidity and mortality.
Coronary care nurses are vital in the implementation of acute phase CR in the CCUs. The independent and interdependent roles of CCNs include medical assessment, risk factor modifications, nutritional counseling, psychosocial interventions and early progressive physical activities to resume ADL and basic self-care. The critical role of a multidisciplinary approach to care is essential to positive outcomes.
Despite the global acceptance of acute phase CR practices, its implementation has been barricaded by important barriers in CCUs. CCNs are vital to delivering optimal level of care during acute phase CR, however multifactorial delays and limited practices in this setting contributed to reinfarction, morbidity and mortality.
The current study aimed to identify barriers to acute phase CR practices for patients with ACS.
Materials and method
A descriptive research design was utilized in this study. The study was conducted at two CCUs of the AMUH.
Study subjects comprised a convenience sample of 100 patients and all CCNs (25) offering direct patient care to patients with ACS.
Data for the study were obtained using the following tools:
Tool I: acute phase CR assessment: it is developed by the researcher after reviewing the relevant literature to identify practices of acute phase CR for patients with ACS.
Tool II: Patients’ awareness regarding cardiac rehabilitation Knowledge structured interview: it is developed by the researcher after reviewing relevant literature to assess patients’ awareness regarding CR knowledge.
Tool III: Barriers to acute phase CR for patients with ACS questionnaire: it is developed by the researcher to identify health care providers related barriers of acute phase CR. The barriers were grouped into three categories;
patient related barriers, health care provider related barriers and organizational related
barriers.
Method
An official letter was send to the director Alexandria Main University Hospital
(AMUH) and permission was granted. A pilot study was carried out on ten patients
and three CCNs to evaluate clarity, feasibility and applicability of the tools. Informed
consent was obtained from the studied patients and CCNs after explanation of the aim
of study with emphasis on their privacy, confidentiality and right to withdraw at any
time. The studied patients observed for three consecutive days using acute phase CR
practices observational checklist and assessed for physical activity intolerance.
Patients asked to self- report awareness about CR knowledge. Barriers to acute phase
CR practices for patients with ACS questionnaire was distributed to CCNs in the three
different shifts during their break times. The researcher was available to clarify and
answer any questions. Data collection was done over four months.
Results of the current study were as follows:
I: Acute phase CR practices
Implementation of acute phase CR practices were limited and performed
independently. In the first 12 hrs of CCUs admission 100% of the studied patients
didn’t perform range of motion exercises. 98% of the studied patients were positioned
themselves in bed independently. Regarding seated ADL, more than half of the
studied patients were performed hygiene and toileting in seated position
independently (63%, 63%) respectively. Regarding standing ADL, more than one
quarter of the studied patients were performed ADL in standing position
independently (37%).
Regarding the second 12 hrs, second and third day of CCUs admission 100%
of the studied patients didn’t perform range of motion exercises. The majority of the
studied patients were positioned themselves in bed independently (98%). Regarding
seated ADL, more than one quarter of the studied patients were performed hygiene
and toileting in seated position independently (41%,40%, 40%) respectively.
Regarding standing ADL, more than half of the studied patients were performed ADL
in standing position independently (59%, 60%, 60%) respectively. All of the studied
patients didn’t perform bathing in sitting or in standing position (100%).
Physical activity intolerance was variable along three days of CCUs admissions.
More than three quarters of the studied patients (88%) had symptoms such as severe
persistent chest pain and dyspnea (III, IV) in the first 12 hrs of CCUs admissions in
comparison with the second 12hrs, second and third day (30%, 5%and 5%)
respectively. Regarding heart rate, it can be noted that 20% of the studied patients had
changes in heart rate >120b/m or <40b/m in the first 12 hrs of CCUs admissions in
comparison with the second 12hrs, second and third day have minimal changes (13%,
2%).
II: Patients’ awareness regarding CR knowledge
Patients’ awareness regarding CR knowledge was low. 20% of the studied
patients have heard about CR program, but they didn’t know the core components or
benefits.80% of the studied patients had awareness about diagnosis. The lower
awareness were in the basic information about risk factors, diagnostic measures of
ACS and management of emergency conditions (15%, 30%, 20%) respectively. Also,
the lower awareness were in smoking cessation, healthy diet, BP control, DM control,
stress management and medication management (20%, 35%, 32%, 38%, 32%, 28%)
respectively.
III: Barriers to acute phase CR practices for patients with ACS
Considering patient related barriers, the studied nurses strongly agreed that
hemodynamic instability, severity of disease, morbid obesity, knowledge and beliefs,
followed by excessive analgesia and multiplicity of invasive devices were the main
patient related barriers to acute phase CR implementations (84%,80%,72%,32%,32%)
respectively. On the other hand, 24% of the studied nurses agreed that delirium was a
barrier to acute phase CR implementation. Regarding health care providers related
barriers, It can be noted that time constraints were indicated as a key barrier to acute
phase CR implementations, with only 8% of the studied nurses dissenting. The
studied nurses also specified the workload, awareness of CR practices and culture of
the CCUs that physical activity is not seen as apriority are major barriers to acute
phase CR (72%,72%,72%) respectively. Fragmented care among multidisciplinary
health care providers and resistance to change were agreed by the studied nurses as
barriers to acute phase CR practices (20%, 16%) respectively.
In addition to organizational related barriers, it can be observed that 100%
of the studied nurses strongly agreed that financial resources were high barriers to
acute phase CR implementations. The majority of the studied nurses were strongly
agreed that lack of workshops about acute phase CR and lack of policies of
punishment were barriers to acute phase CR (92%, 92%) respectively. Also, the
studied nurses strongly agreed that lack of specific protocols or policies to address
acute phase CR in CCUs, numbers of staff members and lack of supervision about
practices of acute phase CR were also organizational related barriers to acute phase
CR implementations (88%,88%,88%) respectively.
Organizational related barriers had the highest mean percentage score among
other barriers (93.67±13.45), followed by patient related barriers (64.0± 24.73) and
lastly health care providers related barriers (63.67± 27.83). The overall percent score
was 73.78 ±18.11.
IV: Relationship between barriers of CR practices and clinical data
on admission
There was a statistically significant relationship between patient related barriers,
organization related barriers, the overall barriers and diagnosis were statistically
significant (F=2.253 & p=0.027; F=2.402 & p=0.018; F=2.455 & p=0.016)
respectively. Also, There was also a statistically significant relationship between
complicated diagnosis and health care providers related barriers (F=2.023 &p=0.046).
There was also a statistically significant relationship between the low density
lipoproteins and organizational related barriers (F=4.802 & p=0.001). There was also
a statistically significant relationship between health care providers related barriers,
organizational related barriers and total cholesterol and the overall barriers were
statistically significant((F=2.624 & p=0.036; F=2.666 & p=0.015; F=1.735 &
p=0.086; F=2.539 & p=0.043).
The relationships between the procedure/treatment and organizational related
barriers and the overall barriers were statistically significant (F=3.836 & p=0.025;
F=3.068 & p=0.051).There was also statistically significant relationship between
medications and health care providers related barriers and the overall barriers were
statistically significant (F=2.530& p=0.020; F=2.802&p=0.011).
V: Relationship between barriers of acute phase CR practices and
physical activities tolerance
There was a statistically significant relationship between physical activities tolerance
and health care providers related barriers (F=2.020 & p=0.046).
Conclusion and recommendations
It can be concluded from the present study that:
Acute phase CR were poorly implemented in CCUs. It includes combination of
medical assessment, risk factor modifications, nutritional counseling, psychosocial
interventions, early progressive physical activities to resume ADL and basic self-care
after discharge from the hospital. The majority of the studied patients’ had lower
awareness regarding CR knowledge and risk factors modifications. The majority of
the studied patients had performed physical activities independently. Although, the
majority of the studied patients had tolerated some components of acute phase CR
after the first12 hrs from CCU admissions, they didn’t implemented.
The current study indicated that there were barriers that categorized into patient,
health care providers and organizational related barriers. Organizational related
barriers which reported by the most of the studied CCNs as the highest barriers to
acute phase CR. Shortage of staff, lack workshops about acute phase CR practices and
lack of in-service trainings to update CCNs were also pointed as main barriers to
acute phase CR. Time constraints, work load, unawareness and insufficient
knowledge were identified as key health care provider’s related barriers to acute phase
CR implementations. Hemodynamic instability, severity of disease and morbid
obesity were reported as chief patient related barriers in this study.