Principal Investigators: LTC Joy Walker & LTC Robin Smith, US Army Nurse Corps, Walter Reed Army Medical Center, Washington DC; Medical Monitor: LTC Houman Tavaf-Motamen, US Army Medical Corps Walter Reed Army Medical Center, Washington DC; Associate Investigator: Dr. Loretta Schlachta-Fairchild, iTelehealth Inc., Frederick MD. In grateful acknowledgement of the following Research Supporters: COL Pat Patrician, AN; COL John Cho, MC; MAJ Charles Mulligan MC; COL Marina Vernalis MC; CPT Carrie Schneider, MS.

PURPOSE/AIMS:

This protocol evaluated the feasibility of a remote, home-based post discharge cardiac monitoring rehabilitation program for post-operative CABG surgery patients. It compared the outcomes of standard post-discharge CABG care with care augmented by telenursing visits. Following CABG surgery, and often despite an uneventful in-hospital postoperative course, patients remain at risk for complications. Complication rates range from 4.8% to 26.8%. i.e. cardiac arrhythmias, pulmonary complications, wound infections, decreased activity tolerance, social isolation, and depression. Post CABG Mortality rates also varied from 0.8% to 15.5 %, (Am Heart J 138(1):69-77, 1999. © 1999 Mosby)

DESIGN/SAMPLE:

This descriptive study used a two-group repeated measures design. The convenience sample consisted of 8 consecutive standard care patients and 4 telenursing patients. The standard care patients received post-operative discharge instructions and information on locations of cardiac rehabilitation centers in the Washington area. The telenursing group received post-operative discharge instructions and locations plus were enrolled in a structured cardiac rehabilitation program and received telenursing monitoring visits to include surgical incision assessments, vital sign monitoring (HR, 02 sat, BP, 3-lead ECG), a standardized, medically approved pain/physical assessment and brief educational interventions and support during each telenursing visit.

Patient Unit: Digital camera (hi resolution)/tripod BP, HR, 02 sat; 3- lead ECG/10 second rhythm strip	Patient Significant other transported equipment & MD approved manual post discharge.

LTC Joy Walker initiates telenursing visit per WRAMC IRB
approved research protocol & per Physician-approved
Telenursing Clinical protocols to standardize visits.

FINDINGS:

There were no significant differences between the control and intervention group on any variable except emotional well-being at baseline. In this case, the control group had lower scores. This difference had disappeared by 8 weeks. Overall, respondents had high scores for: 1) healthcare satisfaction; 2) cardiovascular risk reduction knowledge; and 3) telemedicine perception/satisfaction (intervention group only). There were no differences on these variables between groups nor over the course of the data collection. Significant differences in both groups were seen from baseline to 16 weeks on variables that reflected physical function: 1) self efficacy for walking; 2) physical functioning; 3) role limitations due to physical health; 4) social functioning; and 5) pain. Differences occurred between baseline and 8 weeks and persisted to 16 weeks. Energy/fatigue showed a significant trend but did not achieve statistical significance. The pattern of findings indicate that the two groups, control and experimental, were not significantly different, except on the one variable (emotional well-being) at baseline. This difference disappeared by 8 weeks. Because the two groups are similar, comparison of outcomes at 8 and 16 weeks are valid. Sternal Infection Rates: Three of the 11 subjects in the control group had sternal infections post discharge. None of the 4 intervention group subjects had sternal infections post discharge. This difference was tested by use of a Chi-square. There was no statistical difference between the groups on sternal infection. However, the presence of infection is always a concern so even though there is no statistical difference, clinically, this finding probably warrants further investigation. The fact that there were no differences between the control and experimental groups supports delivering the post-surgical intervention via telemedicine. This is further supported by the fact that the experimental group had high levels of satisfaction with the telemedicine intervention and this did not change over the course of the data collection.

CONCLUSION:

No adverse events occurred. Subjects were highly satisfied with the telenursing intervention. The approach filled a gap in care between discharge and the beginning of cardiac rehabilitation 12 weeks post-discharge, at a time when complications are likely. There was no difference in outcomes, safety or satisfaction of subjects with telenursing compared with the control group findings.

This study demonstrated the feasibility and safety of home telenursing for post discharge open heart surgery patients. The sample for this study is small and thus these findings cannot be generalized to a larger population. Still, the fact that there were significant outcomes, supported by adequate power, gives support to further research exploring the use of telemedicine in a variety of patient populations and settings. Given that this initial study used the technology with relatively healthy post op patients, further research is indicated to determine if improvements in outcomes/reductions in complications for higher risk patients post-discharge for may be gained by this approach.