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Quality improvement programme
Developing and delivering a hybrid Cardiac Rehabilitation Phase II exercise program during the COVID-19 pandemic: a quality improvement program
  1. Javier Loureiro Diaz1,
  2. Liam David Foster2,
  3. Praveen Jayaprabha Surendran1,
  4. Prasobh Jacob1,
  5. Omar Ibrahim1,
  6. Poonam Gupta3
  1. 1Cardiac Rehabilitation Department, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
  2. 2Cardiac Rehabilitation Department, Cardiff and Vale University Health Board, Cardiff, UK
  3. 3Performance Improvement Department, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
  1. Correspondence to Mr Javier Loureiro Diaz; JLOUREIRODIAZ{at}GMAIL.COM

Abstract

The COVID-19 pandemic resulted in the cessation of approximately 75% of cardiac rehabilitation (CR) programmes worldwide. In March 2020, CR phase II (CRP2) services were stopped in Qatar. Multiple studies had shown safety, effectiveness, reduced cost of delivery and improved participation with hybrid CR. A multidisciplinary team reviewed various alternative models for delivery and decided to implement a hybrid CRP2 exercise programme (HCRP2-EP) to ensure continuation of our patient care. Our aim was to enrol in the HCRP2-EP 70% of all eligible patients by 30 September 2020. Institute for Health Care Improvement’s collaborative model was adopted. Multiple plan–do–study–act cycles were used to test change ideas. The outcomes of the project were analysed using standard run chart rules to detect the changes in outcomes over time. This project was implemented from March 2020, and the male patients enrolled between August 2020 and April 2021, with sustained monthly median enrolment above target of 70% throughout. As for our secondary outcome, 75.8% of the male patients who completed HCRP2-EP showed a meaningful change in peak exercise capacity of ≥10% (mean change 17%±6%). There were no major adverse events reported, and the median Patient Satisfaction Score was 96% well above the institutional target of 90%. This shows a well-designed quality improvement programme is an appropriate strategy for implementing HCRP2-EP in a clinical setting, and HCRP2-EP is a feasible, effective and safe intervention in eligible male patients with cardiovascular disease.

  • COVID-19
  • Exercise
  • Healthcare quality improvement
  • Rehabilitation
  • Coronary Disease

Data availability statement

All data relevant to the study are included in the article or uploaded as online supplemental information.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjoq-2022-002202

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    WHAT IS ALREADY KNOWN ON THIS TOPIC

    • Multiple studies have shown safety, effectiveness, reduction in the cost of delivery and improved participation with hybrid cardiac rehabilitation phase II exercise programme (HCRP2-EP). This quality improvement (QI) needed implementation to ensure continuity of cardiac rehabilitation patient care in the time of the COVID-19 pandemic.

    WHAT THIS STUDY ADDS

    • A well-designed QI program is a feasible and effective strategy for implementing an HCRP2-EP intervention in a clinical setting through the means of providing a guiding structure and outcome follow up.

    HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

    • HCRP2-EP may be adopted as a standard practice outside the context of COVID-19 pandemic as a feasible, effective, safe, cost-saving intervention, which may lower barriers of access for patients. This practice should be incorporated into institutional policy.

    Background

    Cardiac rehabilitation (CR) is a coordinated multifaceted intervention designed to optimise a cardiac patient’s physical, psychological and social functioning, in addition to stabilising, slowing or even reversing the progression of their underlying cardiac condition, thereby reducing morbidity and mortality.1 CR is recommended after acute coronary syndrome, chronic coronary syndrome, heart failure, percutaneous coronary intervention and coronary artery bypass graft surgery.1–3 Benefits of CR are broad and include lower risk of cardiovascular mortality,4 decrease in rehospitalisations over 1 year and an increase in physical function and quality of life.2 3 Much of the clinical benefit of CR has been attributed to an increase in peak exercise capacity from participation in a structured exercise programme5 6 and the associated physiological effects on coronary endothelial function, insulin resistance, blood pressure (BP), inflammatory markers and fibrinolytic state.6–8

    CR is usually divided in three distinct phases. Phase I is an inpatient acute care management intervention. Phase II is an outpatient comprehensive programme including exercise training and non-exercise components, which aims to improve peak exercise capacity and overall cardiovascular health. Phase III is a community-based continuation of phase II.9 10 CR programmes have also evolved to become disease management and secondary prevention services.8 11–13 Traditionally, the first choice for CR remains hospital-based, however, various alternatives such as all-virtual and hybrid CR are available.14–16

    The COVID-19 pandemic impacted CR delivery around the globe. Approximately 75% of CR programmes worldwide stopped services, with others reducing components delivered, and/or changing mode of delivery with little opportunity for planning and training.17 18 CR components most affected were supervised exercise training, inclusion of family and informal caregivers, end of programme reassessment and peak exercise capacity testing.18

    Multiple studies have shown the safety, effectiveness, reduced cost of delivery and improved participation with hybrid CR phase II exercise programme (HCRP2-EP), therefore it became imperative to implement it locally to ensure continuation of patient care.2 13 15 19–24

    Problem description

    The COVID-19 pandemic stressed the capabilities of Qatar’s Healthcare System as a whole and had long-lasting implications on the delivery of CRP2. CRP2 services at our facility stopped on 16 March 2020. The unexpected stoppage affected new patient enrolment, continuation of CR delivery for the currently enrolled patients, and significantly impacted our ability to measure the efficacy of the intervention at both patient and programme management level. Hospital-based sessions resumed on 24 August 2020. In addition, patients with pre-existing cardiovascular disease (CVD) had an increased risk of severe COVID-19 disease and worse outcomes, including death, compared with other clinical populations.25 Infection Control (IC) measures implemented limited hospital-based capacity to 25%. Our team identified this as an area for improvement and decided to run a quality improvement (QI) project to develop and implement an HCRP2-EP.

    Setting

    In our hospital, CRP2 involves a multidisciplinary team (MDT) of cardiologists, exercise physiologists, physiotherapists, nurses, pharmacists, occupational therapists and dietitians. The exercise-related intervention includes initial and final assessment of peak exercise capacity via symptom-limited exercise test and supervised exercise training.

    Exercise intervention is group-based up to eight patients per group, separated by gender. There are 2 days or a 3 days per week programmes. Exercise duration is 60 min, comprising a 10 min warm-up and cool-down, with an exercise circuit of 3–6 exercises, 6–12 min per exercise, of a combination of cardiovascular machines and dumbbells. Programmes are individually tailored to match patient’s requirements. Exercise intensity is determined based on the symptom-limited exercise test, as a percentage of heart rate reserve ranging from 40% to 90% depending on the patient’s characteristics, clinical status, risk category, and current and past level of physical activity (PA).

    Patients are categorised as low, intermediate or high risk according to American Association of Cardiovascular and Pulmonary Rehabilitation guidelines for the risk stratification for cardiac events during exercise prescription10 and Canadian Association of Cardiac Rehabilitation guidelines26 for metabolic risk stratification. Our programme includes 18–36 supervised exercise sessions depending on the patient’s risk category,10 over a period of 12 weeks, with a target compliance of more than 80%. ECG is continuously monitored for all patients and may be discontinued after a minimum number of ECG supervised sessions10 with the approval of the MDT.

    Moreover, patients receive assessment and counselling by the MDT and is referred to psychiatric clinics, smoking cessation clinics and cardiometabolic clinics when necessary.

    Rationale

    There is a positive association reported between time of enrolment, total number of sessions attended and compliance to CR with improved health outcomes.27–30 There is compelling evidence that delaying the start of CR is associated with less improvement in peak exercise capacity, poorer uptake, attendance and completion rates.17 31 32 Temporary interruptions to CRP2 may yield major unintended negative consequences associated with the progression of disease coupled with an increased risk of recurrent cardiac events.33

    Aim statement

    To enrol 70% of eligible patients into HCRP2-EP at our cardiac centre by 30 September 2020.

    Objectives

    1. To ensure uninterrupted provision of supervised CRP2 exercise sessions during the COVID-19 pandemic via HCRP2-EP.

    2. To implement a new CRP2 delivery structure.

    3. To achieve equal or more than 10% improvement in the peak exercise capacity after completion of the HCRP2-EP programme.

    Inclusion criteria

    All CVD patients with a diagnosis of acute coronary syndrome (ST-elevation myocardial infarction, non-ST-elevation myocardial infarction, unstable angina), chronic coronary syndrome (coronary artery disease, stable angina), coronary intervention (coronary artery bypass grafting, percutaneous coronary intervention), heart failure, valve disease/valve repair, or cardiomyopathy enrolled in CRP2.

    Exclusion criteria

    • Not clinically stable.

    • History of cardiac arrest (not in the context of acute coronary syndrome), ventricular tachycardia and/or other life-threatening arrhythmias.

    • Left ventricle ejection fraction<30%.

    • Horizontal or down-slopping ST depression or other significant ECG changes during the initial exercise test.

    • Identified risk of fall at initial screening.

    • The patient did not complete the minimum number of hospital-based supervised exercise sessions (table 1).

    • Presence of technological barrier (poor computer literacy and/or lack of access to internet connection).

    • The patient is not interested and or does not give consent for participation.

    View this table:
    Table 1

    Criteria to partake in home-based exercise sessions, including the minimum number of hospital-based sessions before transfer

    Methodology

    Institute for Health Care Improvement’s collaborative model for improvement was adopted.34 Multiple plan–do–study–act (PDSA) cycles were used to test change ideas. The MDT together with a quality adviser reviewed various global models of alternative CRP2 delivery systems to identify an appropriate model. The team decided to implement HCRP2-EP. We identified barriers to implementation using a fishbone diagram (figure 1). Pareto analysis categorised the most significant barriers (online supplemental material).

    Supplemental material

    Figure 1
    Figure 1

    Cause and effect (‘fishbone’) diagram. CR, cardiac rehabilitation; HYCRP2, hybrid cardiac rehabilitation phase II; PC: personal computer; SOP, standard operational procedure.

    Changes tested

    We tested various small changes in order to continue to support patients who were enrolled in CRP2 during the time-of-service suspension.

    PDSA 1: remote PA counselling

    Immediately after the suspension of services, PA counselling via telephone started including assessment of PA status via International Physical Activity Questionnaire (IPAQ), advice on types of indoor exercise programmes, intensity, progression of exercise and safety measures. Of 63 active patients, 100% were phone counselled within 3 days of CRP2 stoppage.

    Feedback from clinicians and patients was collected, which showed this intervention helped patients to continue exercising at home. A meeting was conducted to reach agreement on components and guiding principles of counselling,35–42 and a common guiding script was formulated (online supplemental material). This change was adopted.

    Within 4 weeks, all patients were phone counselled two times. Sedentary and minimally active patients (IPAQ<600 metabolic equivalent of task (MET)-min/week) were identified, and an additional weekly phone counselling was performed.

    PDSA 2: creation of short video ‘CR at home during COVID-19’

    The main patient feedback during PDSA 1 was ‘difficulty in performing correct and safe exercise at home’. MDT, in collaboration with the corporate communications department created a 5 min educational video explaining:

    1. Precautions: space, medication, self-monitoring of symptoms.

    2. Reinforcing public health policies regarding infection control.

    3. Appropriate warm-up and cool-down exercises.

    4. Demonstration of various home-based exercises for the conditioning phase, at different intensity levels.

    5. Self-monitoring of exercise intensity via rate of perceived exertion (RPE).43–47

    6. Emergency management.

    This video was sent via email to two patients with written instructions. Follow-up calls were given to get their feedback. PDSA was adopted, and the video was sent to all patients.

    PDSA 3: implementing the home-based exercise component

    PDSA 3a: selection and customisation of the telehealth platform

    Four popular teleconference platforms commercially available were tested. Difficulty in connectivity, lack of customisation and non-compliance with Health Insurance Portability and Accountability Act (HIPAA) privacy requirements, made these platforms unsuitable. Therefore, these changes were abandoned.

    An HIPAA-compliant telehealth platform was provided and approved by Ministry of Public Health (MOPH). Clinic workflows were customisable. Workflows for a group exercise clinic, a group education clinic, and one-to-one counselling clinic were developed. We received technical support from our institution and from an external contractor. Group exercise clinic privacy rules (clinician can see and hear all patients; patients can see and hear only the clinician) were specifically developed for our clinic by software developers.

    PDSA 3b: designing the exercise component of the home-based sessions

    The exercise physiology and physiotherapy team agreed on an initial draft for a home-based no-equipment required moderate intensity exercise programme. Every clinician had at least one practice session as an instructor and one acting as a patient. After every session, a team meeting was conducted, and modifications were incorporated if unanimous agreement was reached. The final model was tested on the other CR department staff and their family members, and feedback was incorporated. To accommodate all patients irrespective of their risk category and physical ability, standard exercise regressions and progressions for each exercise were adopted. Finally, we successfully piloted it in two patients and then applied it to all active eligible patients.

    PDSA 3c: optimisation of access to the telehealth platform

    After implementing PDSA 3b, the login process was found to be difficult for the patients. We engaged in collaboration with Ithe Information Technologies (IT) department, MOPH and software developers, and the login interface was modified. In the meantime, to mitigate the issue, several strategies were implemented:

    • Email support: standardised download links, installation instructions, troubleshooting guide were sent to patients from corporate group email address.

    • Phone support: an installation call was done via regular phone call, followed via a test call through the telehealth platform to ensure correct functioning.

    • One-to-one introductory counselling session to explain check-in and check-out process, exercise component, safety of the room environment, clinical considerations as medicine compliance, availability of machines to check blood sugars, BP and emergency procedures were done.

    • To facilitate bookings and notifications, a short messaging service gateway was also incorporated.

    PDSA 4: remote telemetric ECG monitoring during home-based exercise

    The telehealth platform did not fully support patients who required additional ECG monitoring. We supplemented the telehealth platform with a remote ECG telemetry monitoring system. This change was adopted as it allowed for selected patients who needed close monitoring of ECG and heart rate during exercise to enrol in the HCRP2-EP.

    For remote patients, we scheduled individual hospital visits to collect the ECG equipment and test it. For those transitioning from hospital-based to home-based sessions, we performed the final two sessions on the remote telemetric ECG monitoring system, instead of the usual ECG telemetry system, to familiarise the patients with the equipment before the transfer.

    PDSA 5: modification of CRP2 delivery structure (criteria for transfer and timing)

    CRP2 delivery structure was modified to provide a clear understanding of the optimal patient pathway towards HCRP2-EP, depending on risk category and patient performance during the hospital-based sessions. The following is based on available guidelines and MDT’s input:

    • Five types of sessions were defined: hospital-based ECG monitored, hospital-based RPE Scale monitored only, home-based non-supervised remote ECG monitored, home-based supervised and remote ECG monitored, home-based supervised and RPE Scale monitored only.

    • Criteria to partake in home-based exercise sessions, including establishing the minimum number of hospital-based sessions before transfer,10 were agreed on (table 1).

    To ensure safety, approval by MDT for transfer to home-based exercise was required. A transfer eligibility criteria checklist was developed (online supplemental appendix A).

    Supplemental material

    Since patients would be exercising away from hospital, clinical emergency protocol was modified as to follow MOPH protocol. For technological issues (critical and non-critical), the instructor issued verbal instructions at the beginning of each session.

    PDSA 6: staff training

    Two members of the MDT became the champions for the adoption of the telehealth platform. Their responsibilities include leading the telehealth platform workflow customisation with the institutional IT and software developers, and the dissemination of technology to the other clinical staff. Multiple online and one-to-one training sessions were conducted to introduce all staff to the telehealth platform. Additionally, to support staff, the following was developed:

    • A guide on the necessary preparations before home-based exercise sessions.

    • A guide on how to lead a home-based group exercise session via telehealth platform.

    • Two checklists for the nursing team to guide online check-in and check-out.

    The effectiveness of the education and the knowledge of the staff was evaluated using the teach-back method.

    PDSA 7: minimising risk of COVID-19 infection during the hospital-based sessions

    IC practices were implemented under guidance from an IC department to ensure safe environment for hospital-based exercise sessions:

    • Phone triage on the previous day to hospital-based exercise.

    • Traige by the nursing team on the day of exercise, outside of the exercise space, including checking status of official COVID-19 contact tracing application of Ministry of Interior of Qatar.

    • Individual assessment rooms outside the exercise area.

    • Installation of high efficiency particle arresting filter.

    • Segregation of gym floor into individual exercise areas.

    • Installation of hand sanitiser dispensers in each individual exercise area.

    • Use of personal protective equipment (PPE) as per institutional policies and implementation of PPE donning and doffing areas.

    • Increasing cleaning measures after each session as per institutional policies.

    PDSA 8: video support to promote long-term engagement in PA

    The scope of the original CR at home exercise video (see PDSA 2) was expanded:

    • A written script for a full 1-hour home exercise video was submitted for approval by institutional patient and family education (PFE) committee and media department.

    • The video link was sent via email to the patient if: unable to attend hospital-based sessions due to COVID-19 restrictions, unable to attend the hospital-based or home-based sessions due to incompatibility with class timings, or to promote PA engagement after discharge from HCRP2-EP

    After successful implementation we expanded video support in two ways:

    • Tailoring to the patient: four full 1-hour videos of four different levels of intensity.

    • Language: initially recorded in English, we prepared voice-over and subtitles in Arabic for all videos.

    PDSA 9: tracking technical issues

    To understand the sustainability, scalability and quality of the HCRP2-EP, an online technical issue tracking form was developed. The MDT logged any technical issues through a QR code, which automatically sent a notification to one of the technology adoption champions.

    We started to track technology-related issues from January 2021 only. Non-critical issues were defined as any issues which did not prevent treatment from being completed. Critical issues were defined as any issue which may prevent a session from starting or completing. For all issues, we specified origin (patient side, clinician side, both sides) and the technology affected.

    Main critical-issues reported affected the privacy settings or the capacity of the telehealth application. These were solved by liaising with our institution’s IT team to downgrade the software version until the main architecture of the software supported our specific needs.

    Study of intervention

    Data were retrospectively and weekly gathered. Tested changes were assessed using qualitative and quantitative measures.

    Outcome measures

    • Enrolment in HCRP2-EP.

    • Improvement of peak exercise capacity.

    Process measures

    • Compliance with hospital-based versus home-based exercise sessions.

    • Timing of transfer to home-based exercise sessions.

    • Reliability of technology.

    Balance measures

    • Patient Satisfaction Score (PSS).

    • Rate of exercise-related major and minor adverse events.10

    • Estimated savings in the cost of clinical and non-clinical consumables.

    Results

    HCRP2-EP was initiated in March 2020, and the patients enrolled between July 2020 and April 2021. A total of 96 male patients enrolled in CRP2, of which at initial assessment, 56 (58.3%) were eligible for HCRP2-EP (table 2).

    View this table:
    Table 2

    Summary of HCRP2-EP elegibility, enrollment and completion

    The clinical characteristics of all participants in HCRP2-EP are shown in table 3. This table is split into improvers (those who achieved benchmark percentage improvement as per our institutional clinical protocol of ≥10% increase in peak exercise capacity) and those who did not (non-improvers).

    View this table:
    Table 3

    Clinical characteristics of patients who significantly improved or not their peak exercise capacity in a symptom-limited exercise test after participation in HCRP2-EP

    For those who participated and completed there was a total of 1135 hospital-based exercise hours and 529 home-based exercise hours.

    Primary outcome: enrolment in HCRP2-EP

    Home-based sessions started from July 2020, and first participating patients were discharged from August 2020 onwards (figure 2, table 2). We audited every patient file for eligibility and enrolment at date of discharge. From July 2020 to April 2021, there were 56 eligible patients. A total of 51 patients (91.1%) enrolled and 43 (84.3%) completed HCRP2-EP. Only on February 2021 were there no discharged patients. Overall, monthly median enrolment was 90%.

    Figure 2
    Figure 2

    Percentage of eligible patients who enrolled in hybrid cardiac rehabilitation phase II exercise programme.

    Of the 40 non-eligible patients, 9 (23%) completed hospital-based before the home based-component effective implementation, 15 (38%) did not complete the required number of hospital-based sessions, 6 (15%) did not give consent to participate in home-based sessions, 5 (13%) due to medical advice and 4 (10%) due to technological barrier (computer literacy and lack of access to internet connection) (online supplemental material).

    Of the 5 non-enrolled patients, 3 (60%) dropped out of CRP2 before completing the required number of hospital-based exercise sessions before the transfer eligibility point and 2 (40%) declined due to non-convenient timing of the home-based sessions (online supplemental material).

    Secondary outcome: improvement in exercise capacity

    To test the HCRP2-EP effectiveness, symptom-limited exercise tests were performed pre-to-post intervention (online supplemental material). Out of the 33 patients who completed HCRP2-EP with a final symptom-limited exercise test, 25 patients (75.8%) showed ≥10% improvement in peak exercise capacity (mean 17%±6%), while 8 patients (24.2%) did not (mean 4%±5%) (table 3).

    Process measures

    Compliance to HCRP2-EP remained well above the institutional target of 80%, where monthly median was 95% for hospital-based sessions and 92% for home-based sessions (figure 3).

    Figure 3
    Figure 3

    Percentage compliance to hospital-based and home-based exercise sessions in patients participating in hybrid cardiac rehabilitation phase 2 exercise program.

    For the timing of transfer from hospital-based to home-based (table 1), MDT established a median target point of before 50% of their prescribed total number of sessions. The overall monthly median transfer point was within target (46%) (online supplemental material).

    • Low risk: median 7th session (39%).

    • Moderate risk: median of 10th session (41%).

    • High risk: median of 22nd session (61%).

    To assess the reliability of the adopted technology, from January 2021 we monitored 217 sessions (41% of total home-based individual exercise sessions). A total of 32 (14.7%) sessions experienced non-critical issues and 21 (9.6%) had critical issues that prevented the planned treatment from being completed. Overall, we had a median of 14 issues per month, of which, the critical issues monthly median accounted for 29% of all issues. In regard to equipment at fault, either solely or various pieces of equipment simultaneously failing at the same session, 57% of the time an issue was reported, the telehealth platform was at fault, 33% of the times it was related to the remote ECG telemetry device and 14% was due to the internet connection on either the patient or the providers side.

    Balance measures

    PSS remained above institutional target of 90%. Preintervention 2019 median was 95% and during intervention median it was 96% (online supplemental material).

    We monitored 1135 hospital-based patient exercise/hours and 529 home-based patient exercise/hours. There were no major adverse events reported for hospital or home-based exercise sessions. Overall, 1.94% of the hospital-based sessions had minor adverse events reported versus 0.76% for home-based.

    Cost of consumables was reduced by a monthly median of 34%.

    Discussion

    HCRP2-EP enabled continuity of patient care at the time of the most intensive restrictions during the pandemic. The key for a successful implementation of HCRP2-EP was underpinned in two factors: clinical staff leading the adoption of the technology by assuming the role of technology champions within the CR department and second, the tailoring of the telehealth platform clinics to fit the specific needs of the CR service and patients.

    At the time of service stoppage, we had six female patients, three had already completed the minimum number of sessions and were discharged. Two were ineligible and only one patient was eligible for HCRP2-P. Over the 10 months of this QI project, only 11 (10.5%) additional female patients were assessed compared with the 96 (89.5%) males. This is in line with our historical female participation rate, which for the period 2016–2023 (n=1315) was 9.5%. It is worth noting that in our programme, we offer women-only sessions as the CR option for female patients. In Arab countries such as Qatar, women-only CR is related to religious beliefs and cultural values around gender segregation, so females can exercise comfortably.48 Generally, women participating in women-only CR programmes are significantly more comfortable in their workout attire and perceive the environment as less competitive.49 There is also a growing trend toward implementation of women-only CR in Western countries. While the International Council of Cardiovascular Prevention and Rehabilitation 2022 Clinical Practice Guideline for Women-Focused Cardiovascular Rehabilitation does recommend that women should be provided the choice of participating in hospital-based or a hybrid model…. it also states among its recommendations that ‘the CR environment should be optimised to meet women’s preferences, values and goals’, including consideration of privacy and that ‘inclusion of male support persons in some elements of women-only programmes might not be appropriate’.48 Furthermore, lack of human resources is perceived as the greatest barrier to CR provision overall. Therefore, pairing the above culturally relevant cricumtances, concerns surrounding privacy, and staffing constraints due to lack of female therapist due to COVID facility deployment, resulted in no female patients enrolling in HCRP2-EP. All women participated in the reduced capacity hospital-based CR, of which 63% completed.

    The feasibility of the home-based component of HCRP2-EP was proven by; the high level of enrolment (91.1% of eligible male patients, 90% monthly median enrolment) (figure 2), the low technological barrier reported with only 4 out of 40 (10%) ineligible patients, and moreover, the high compliance (92%) to the home-based component of HCRP2-EP (figure 3). It should be acknowledged that compliance rates for both home-based and hospital-based were abnormally high when compared with available evidence.23 50 We hypothesised this was due to patients having more time available at home due to pandemic restrictions, and a likelihood that only motivated and engaged patients would have chosen to participate in exercise during the pandemic period, among other factors.

    In terms of intervention effectiveness, the monthly median percentage of patients who improved their peak exercise capacity more than the departmental target of 10% pre-to-post intervention was 75%, which is above both our institutional target of 70%, and our historical median for the period 2013–2019 of 68%. These results are also in line with what has previously been reported in several studies.51 52

    For technology-related critical issues that prevented the planned treatment from being completed, the source of the problem was always on the clinician side (100%) and represented 9.6% of total observed home-based exercises sessions. Overall, 3.2% of total sessions experienced issues with the remote ECG telemonitoring equipment and 6.4% on the telehealth platform. For non-critical issues 10.1% of the sessions experienced issues from patient’s side, 2.3% from clinician side and 2.3% from patient and clinician side simultaneously.

    There were no major adverse events reported neither during hospital-based nor home-based exercise sessions. Hospital-based sessions had a rate of 1 minor adverse event in every 51 individual sessions and home-based exercise sessions a rate of 1 in every 132 individual sessions (online supplemental material). These rates may purely reflect the earlier point of treatment for the patient during hospital-based exercise sessions, and the strict transfer criteria needed to be met for home-based exercise sessions (see PDSA 5). During the programme, only 1 patient out of 51 enrolled (2%) had to return to hospital-based sessions due to post exercise dizziness related to hypoglycaemia and hypotension.

    The intervention proved to be cost-saving. Cost of consumables was calculated by determining the cost per unit for all clinical and non-clinical consumables used in hospital-based sessions. The savings were calculated at patient discharge as the difference between the projected cost if the patient had completed all sessions as hospital-based versus actual cost after participation in HCRP2-EP. Monthly median cost in consumables was reduced by 34%.

    Limitations

    Comparison of our primary outcome measure could not be done, since we do not have baseline data as HCRP2-EP was a newly implemented intervention.

    Only male patients participated in HCRP2-EP due to the intrinsic constrains related to the cultural and religious background of the country, and the lack of female therapist available to conduct women-only sessions during the pandemic due to COVID-19 deployment. Further research should be conducted to assess feasibility, effectiveness, safety and acceptance of HCRP2-EP to include a larger and more diverse population, including women.

    Regarding our secondary outcome, the number of patients who completed the programme represented only 17.9% of completed patients in the previous year, therefore a larger sample is needed to confirm our results.

    Tracking of technical issues started only after January 2021.

    Ultimately, with our model, the exercise physiologist or physiotherapist performs each exercise for each session alongside the patients. This model may impose additional physical strain on staff if they must lead multiple sessions daily. Staff well-being should perhaps be considered for implementation as a balance measure.

    Lessons learned

    There is currently a wide range of technology available for clinical use. Careful consideration and test trialling is paramount for successful implementation and adoption among patients and staff. Selected technology must allow customisation to allow scalability, and continuous development and QI. Identification of potential technology champions among clinical staff is key for adapting technology and fostering adoption within their peers. Giving adequate patient information about risks, safety and benefits of HCRP2-EP is important.As is training the patients in the use of technology under supervision before transfer to ensure a smooth transition from hospital-based to home-based sessions.

    It is important to also identify other non-traditional non-clinical stakeholders that may bring complementary knowledge and expertise (IT, communications, PFE…).

    HCRP2-EP affords another option for CR delivery, which may enhance participation and completion. Depending on human resources availability and home-based exercise sessions demand, the physical workload imposed on staff may become a limitation to the expansion of the programme.

    Conclusion

    HCRP2-EP is well accepted by male patients and clinicians as a feasible, cost-saving, effective and safe intervention in eligible male patients with CVD irrespective of their risk category. A well-designed QI programme is effective in implementing HCRP2-EP in a clinical setting.

    Data availability statement

    All data relevant to the study are included in the article or uploaded as online supplemental information.

    Ethics statements

    Patient consent for publication

    Acknowledgments

    We would like to thank Shaza D Ibrahiem, business manager at Shoura BG, for the support on the customisation of the telehealth application including its interface and clinic workflows. We would like to thank Manjunath Srinivasa HITC analyst for troubleshooting all IT related issues and acting as a liaison with the external contractors. We would like to thank the Cardiac Rehabilitation Nursing Team, and Anastasios Rodis (Exercise Physiologist) and Marko Pejakovic (Physiotherapist) for their contributions in the delivery on the home-based exercise sessions. We would like to thank Ted Papasavvas, Mohammed Abdulla A A Al-Hashemi, Mohammad Suliman and Daniel Martinez Bussion for their advice on implementation. We would like to thank Raffi Parseghian, Winston Morris Hycinth, Gino Carlo Agulto for their valuable advice having the exercise support videos recorded, approved and uploaded for the patient’s benefit.

    References

    1. ↵
      1. Taylor RS,
      2. Brown A,
      3. Ebrahim S, et al
      . Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med 2004;116:682–92. doi:10.1016/j.amjmed.2004.01.009
      OpenUrlCrossRefPubMedWeb of Science
    2. ↵
      1. Anderson L,
      2. Thompson DR,
      3. Oldridge N, et al
      . n.d. Exercise‐Based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev doi:10.1002/14651858.CD001800.pub3 Available: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001800.pub3/abstract
    3. ↵
      1. Dibben G,
      2. Faulkner J,
      3. Oldridge N, et al
      . Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev 2021;11:CD001800. doi:10.1002/14651858.CD001800.pub4
    4. ↵
      1. Eijsvogels TMH,
      2. Maessen MFH,
      3. Bakker EA, et al
      . Association of cardiac rehabilitation with all-cause mortality among patients with cardiovascular disease in the Netherlands. JAMA Netw Open 2020;3:e2011686. doi:10.1001/jamanetworkopen.2020.11686
    5. ↵
      1. Vanhees L,
      2. Fagard R,
      3. Thijs L, et al
      . Prognostic value of training-induced change in peak exercise capacity in patients with myocardial Infarcts and patients with coronary bypass surgery. Am J Cardiol 1995;76:1014–9. doi:10.1016/s0002-9149(99)80287-2
      OpenUrlCrossRefPubMedWeb of Science
    6. ↵
      1. Lavie CJ,
      2. Arena R,
      3. Swift DL, et al
      . Exercise and the cardiovascular system: clinical science and cardiovascular outcomes. Circ Res 2015;117:207–19. doi:10.1161/CIRCRESAHA.117.305205
      OpenUrlAbstract/FREE Full Text
    7. ↵
      1. Hambrecht R,
      2. Wolf A,
      3. Gielen S, et al
      . Effect of exercise on coronary endothelial function in patients with coronary artery disease. N Engl J Med 2000;342:454–60. doi:10.1056/NEJM200002173420702
      OpenUrlCrossRefPubMedWeb of Science
    8. ↵
      1. Ades PA,
      2. Savage PD,
      3. Toth MJ, et al
      . High-calorie-expenditure exercise: a new approach to cardiac rehabilitation for overweight coronary patients. Circulation 2009;119:2671–8. doi:10.1161/CIRCULATIONAHA.108.834184
      OpenUrlAbstract/FREE Full Text
    9. ↵
      1. Tessler J,
      2. Bordoni B
      . Cardiac Rehabilitation. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing, 2022. Available: http://www.ncbi.nlm.nih.gov/books/NBK537196/
    10. ↵
      1. Rehabilitation AA of C& P
      . Guidelines for Cardia rehabilitation and secondary prevention Programs-5Th edition (with web resource). Human Kinetics 2013:338.
    11. ↵
      1. Ades PA
      . Cardiac rehabilitation and secondary prevention of coronary heart disease. N Engl J Med 2001;345:892–902. doi:10.1056/NEJMra001529
      OpenUrlCrossRefPubMedWeb of Science
    12. ↵
      1. Linden W,
      2. Stossel C,
      3. Maurice J
      . Psychosocial interventions for patients with coronary artery disease: a meta-analysis. Arch Intern Med 1996;156:745–52.
      OpenUrlCrossRefPubMedWeb of Science
    13. ↵
      1. Ades PA,
      2. Keteyian SJ,
      3. Wright JS, et al
      . Increasing cardiac rehabilitation participation from 20% to 70%: A road map from the million hearts cardiac rehabilitation collaborative. Mayo Clin Proc 2017;92:234–42.:S0025-6196(16)30648-6. doi:10.1016/j.mayocp.2016.10.014
      OpenUrlCrossRefPubMed
    14. ↵
      1. Keteyian SJ,
      2. Ades PA,
      3. Beatty AL, et al
      . A review of the design and implementation of a hybrid cardiac rehabilitation program: AN EXPANDING OPPORTUNITY FOR OPTIMIZING CARDIOVASCULAR CARE. J Cardiopulm Rehabil Prev 2022;42:1–9. doi:10.1097/HCR.0000000000000634
      OpenUrl
    15. ↵
      1. Thomas RJ,
      2. Beatty AL,
      3. Beckie TM, et al
      . Home-based cardiac rehabilitation: A scientific statement from the American Association of cardiovascular and pulmonary rehabilitation, the American heart Association, and the American college of cardiology. J Cardiopulm Rehabil Prev 2019;39:208–25. doi:10.1097/HCR.0000000000000447 Available: https://www.ahajournals.org/doi/10.1161/CIR.0000000000000663
      OpenUrl
    16. ↵
      1. Hwang R,
      2. Bruning J,
      3. Morris NR, et al
      . Home-based Telerehabilitation is not inferior to a centre-based program in patients with chronic heart failure: a randomised trial. J Physiother 2017;63:101–7.:S1836-9553(17)30031-0. doi:10.1016/j.jphys.2017.02.017
      OpenUrlPubMed
    17. ↵
      1. Scherrenberg M,
      2. Wilhelm M,
      3. Hansen D, et al
      . The future is now: a call for action for cardiac Telerehabilitation in the COVID-19 pandemic from the secondary prevention and rehabilitation section of the European Association of preventive cardiology. Eur J Prev Cardiol 2021;28:524–40. doi:10.1177/2047487320939671
      OpenUrl
    18. ↵
      1. Ghisi GL de M,
      2. Xu Z,
      3. Liu X, et al
      . Impacts of the COVID-19 pandemic on cardiac rehabilitation delivery around the world. Cardiovascular Medicine [Preprint]. doi:10.1101/2020.11.11.20230045
    19. ↵
      1. Clark RA,
      2. Conway A,
      3. Poulsen V, et al
      . Alternative models of cardiac rehabilitation: a systematic review. Eur J Prev Cardiol 2015;22:35–74. doi:10.1177/2047487313501093
      OpenUrlCrossRefPubMed
    20. ↵
      1. Santiago de Araújo Pio C,
      2. Beckie TM,
      3. Varnfield M, et al
      . Promoting patient utilization of outpatient cardiac rehabilitation: A joint International Council and Canadian Association of cardiovascular prevention and rehabilitation position statement. Int J Cardiol 2020;298:1–7.:S0167-5273(19)31295-1. doi:10.1016/j.ijcard.2019.06.064
      OpenUrl
    21. ↵
      1. Rawstorn JC,
      2. Gant N,
      3. Direito A, et al
      . Telehealth exercise-based cardiac rehabilitation: a systematic review and meta-analysis. Heart 2016;102:1183–92. doi:10.1136/heartjnl-2015-308966
      OpenUrlAbstract/FREE Full Text
    22. ↵
      1. Piotrowicz E,
      2. Piepoli MF,
      3. Jaarsma T, et al
      . Telerehabilitation in heart failure patients: the evidence and the pitfalls. Int J Cardiol 2016;220:408–13.:S0167-5273(16)31288-8. doi:10.1016/j.ijcard.2016.06.277
      OpenUrl
    23. ↵
      1. Imran HM,
      2. Baig M,
      3. Erqou S, et al
      . Home-based cardiac rehabilitation alone and hybrid with center-based cardiac rehabilitation in heart failure: A systematic review and meta-analysis. J Am Heart Assoc 2019;8:e012779. doi:10.1161/JAHA.119.012779
    24. ↵
      1. Maddison R,
      2. Rawstorn JC,
      3. Rolleston A, et al
      . The remote exercise monitoring trial for exercise-based cardiac rehabilitation (REMOTE-CR): a randomised controlled trial protocol. BMC Public Health 2014;14. doi:10.1186/1471-2458-14-1236
    25. ↵
      1. Aggarwal G,
      2. Cheruiyot I,
      3. Aggarwal S, et al
      . Association of cardiovascular disease with coronavirus disease 2019 (COVID-19) severity: A meta-analysis. Current Problems in Cardiology 2020;45:100617. doi:10.1016/j.cpcardiol.2020.100617 Available: https://linkinghub.elsevier.com/retrieve/pii/S0146280620300943
      OpenUrlCrossRefPubMed
    26. ↵
      CACPR - guidelines [Internet]. 2022. Available: https://cacpr.ca/Guidelines
    27. ↵
      1. Suaya JA,
      2. Stason WB,
      3. Ades PA, et al
      . Cardiac rehabilitation and survival in older coronary patients. J Am Coll Cardiol 2009;54:25–33. doi:10.1016/j.jacc.2009.01.078 Available: https://www.sciencedirect.com/science/article/pii/S0735109709012224
      OpenUrlFREE Full Text
    28. ↵
      1. Martin B-J,
      2. Hauer T,
      3. Arena R, et al
      . Cardiac rehabilitation attendance and outcomes in coronary artery disease patients. Circulation 2012;126:677–87. doi:10.1161/CIRCULATIONAHA.111.066738 Available: https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.111.066738
      OpenUrlAbstract/FREE Full Text
    29. ↵
      1. Hammill BG,
      2. Curtis LH,
      3. Schulman KA, et al
      . Relationship between cardiac rehabilitation and long-term risks of death and myocardial infarction among elderly Medicare beneficiaries. Circulation 2010;121:63–70. doi:10.1161/CIRCULATIONAHA.109.876383 Available: https://www.ahajournals.org/doi/10.1161/circulationaha.109.876383
      OpenUrlAbstract/FREE Full Text
    30. ↵
      1. Johnson DA,
      2. Sacrinty MT,
      3. Gomadam PS, et al
      . Effect of early enrollment on outcomes in cardiac rehabilitation. Am J Cardiol 2014;114:1908–11.:S0002-9149(14)01864-5. doi:10.1016/j.amjcard.2014.09.036
      OpenUrlCrossRefPubMed
    31. ↵
      1. Fell J,
      2. Dale V,
      3. Doherty P
      . Does the timing of cardiac rehabilitation impact fitness outcomes? an observational analysis. Open Heart 2016;3:e000369. doi:10.1136/openhrt-2015-000369 Available: https://openheart.bmj.com/content/3/1/e000369
    32. ↵
      1. Marzolini S,
      2. Blanchard C,
      3. Alter DA, et al
      . Delays in referral and Enrolment are associated with mitigated benefits of cardiac rehabilitation after coronary artery bypass surgery. Circ Cardiovasc Qual Outcomes 2015;8:608–20. doi:10.1161/CIRCOUTCOMES.115.001751 Available: https://www.ahajournals.org/doi/full/10.1161/CIRCOUTCOMES.115.001751
      OpenUrlAbstract/FREE Full Text
    33. ↵
      1. Van Iterson EH,
      2. Laffin LJ,
      3. Crawford M, et al
      . Cardiac rehabilitation is essential in the COVID-19 era: delivering uninterrupted heart care based on the cleveland clinic experience. J Cardiopulm Rehabil Prev 2021;41:88–92. doi:10.1097/HCR.0000000000000585
      OpenUrl
    34. ↵
      1. Picarillo AP
      . Introduction to quality improvement tools for the clinician. J Perinatol 2018;38:929–35. doi:10.1038/s41372-018-0100-4
      OpenUrlPubMed
    35. ↵
      1. Huang HY,
      2. Lin YS,
      3. Chuang YC, et al
      . Application of the Transtheoretical model to exercise behavior and physical activity in patients after open heart surgery. Acta Cardiol Sin [Internet] 2015;31:202–8.
      OpenUrl
    36. ↵
      1. Eshah NF
      . Readiness for behavior change in patients living with ischemic heart disease. Journal of Nursing Research 2019;27:e57. doi:10.1097/jnr.0000000000000336 Available: https://journals.lww.com/jnr-twna/fulltext/2019/12000/readiness_for_behavior_change_in_patients_living.9.aspx
    37. ↵
      1. Russell KL,
      2. Bray SR
      . Promoting self-determined motivation for exercise in cardiac rehabilitation: the role of autonomy support. Rehabil Psychol 2010;55:74–80. doi:10.1037/a0018416
      OpenUrlCrossRefPubMed
    38. ↵
      1. Rahman RJ,
      2. Hudson J,
      3. Thøgersen-Ntoumani C, et al
      . Motivational processes and well-being in cardiac rehabilitation: a self-determination theory perspective. Psychol Health Med 2015;20:518–29. doi:10.1080/13548506.2015.1017509
      OpenUrl
    39. ↵
      1. Kaushal N,
      2. Nemati D,
      3. Gauthier-Bisaillon R, et al
      . n.d. How and why patients adhere to a prescribed cardiac rehabilitation program: A longitudinal phenomenological study of patients with acute coronary syndrome. IJERPH;19:1482. doi:10.3390/ijerph19031482 Available: https://www.mdpi.com/1660-4601/19/3/1482
    40. ↵
      1. Pietrabissa G,
      2. Ceccarini M,
      3. Borrello M, et al
      . n.d. Enhancing behavioral change with motivational interviewing: a case study in a cardiac rehabilitation unit. Front Psychol;6. doi:10.3389/fpsyg.2015.00298 Available: https://www.frontiersin.org/articles/10.3389/fpsyg.2015.00298
    41. ↵
      1. Ski CF,
      2. Thompson DR
      . Motivational interviewing as a brief intervention to improve cardiovascular health. Eur J Cardiovasc Nurs 2013;12:226–9. doi:10.1177/1474515112472271 Available: https://doi.org/10.1177/1474515112472271
      OpenUrlCrossRefPubMed
    42. ↵
      1. Rodríguez-Romero R,
      2. Falces C,
      3. Kostov B, et al
      . A motivational interview program for cardiac rehabilitation after acute myocardial infarction: study protocol of a randomized controlled trial in primary Healthcare. BMC Prim Care 2022;23:106. doi:10.1186/s12875-022-01721-y
    43. ↵
      1. Williams N
      . The Borg rating of perceived exertion (RPE) scale. Occupational Medicine 2017;67:404–5. doi:10.1093/occmed/kqx063 Available: https://doi.org/10.1093/occmed/kqx063
      OpenUrl
    44. ↵
      1. Skinner JS,
      2. Hutsler R,
      3. Bergsteinová V, et al
      . The validity and reliability of a rating scale of perceived exertion. Med Sci Sports 1973;5:94–6.
      OpenUrlPubMed
    45. ↵
      1. Burkhalter N
      . Evaluation of Borg’s perceived exertion scale in cardiac rehabilitation. Rev Lat Am Enfermagem 1996;4:65–73. doi:10.1590/s0104-11691996000300006
      OpenUrlCrossRefPubMed
    46. ↵
      1. Scherr J,
      2. Wolfarth B,
      3. Christle JW, et al
      . Associations between Borg’s rating of perceived exertion and physiological measures of exercise intensity. Eur J Appl Physiol 2013;113:147–55. doi:10.1007/s00421-012-2421-x
      OpenUrlCrossRefPubMed
    47. ↵
      1. Borg G
      . Psychophysical Scaling with applications in physical work and the perception of exertion. Scand J Work Environ Health 1990;16:55–8. doi:10.5271/sjweh.1815
      OpenUrlCrossRefPubMedWeb of Science
    48. ↵
      1. Ghisi GL de M,
      2. Kin SM R,
      3. Price J, et al
      . Women-focused cardiovascular rehabilitation: an international council of cardiovascular prevention and rehabilitation clinical practice guideline. Canadian Journal of Cardiology 2022;38:1786–98. doi:10.1016/j.cjca.2022.06.021 Available: https://linkinghub.elsevier.com/retrieve/pii/S0828282X22004019
      OpenUrl
    49. ↵
      1. Andraos C,
      2. Arthur HM,
      3. Oh P, et al
      . Women’s preferences for cardiac rehabilitation program model: A randomized controlled trial. Eur J Prev Cardiolog 2015;22:1513–22. doi:10.1177/2047487314559275 Available: https://academic.oup.com/eurjpc/article/22/12/1513-1522/5926344
      OpenUrl
    50. ↵
      1. Taylor RS,
      2. Dalal H,
      3. Jolly K, et al
      . Home-based versus centre-based cardiac rehabilitation. Cochrane Database Syst Rev 2015:CD007130. doi:10.1002/14651858.CD007130.pub3
    51. ↵
      1. Chong MS,
      2. Sit JWH,
      3. Karthikesu K, et al
      . Effectiveness of technology-assisted cardiac rehabilitation: A systematic review and meta-analysis. Int J Nurs Stud 2021;124:104087.:S0020-7489(21)00234-0. doi:10.1016/j.ijnurstu.2021.104087
      OpenUrl
    52. ↵
      1. Tegegne TK,
      2. Rawstorn JC,
      3. Nourse RA, et al
      . Effects of exercise-based cardiac rehabilitation delivery modes on exercise capacity and health-related quality of life in heart failure: a systematic review and network meta-analysis. Open Heart 2022;9:e001949. doi:10.1136/openhrt-2021-001949

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    Footnotes

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    • Contributors All authors were involved in the drafting the article or revising it critically for important intellectual content, and all authors approved the final version to be published. JLD and LDF were responsible for the concept, design, development and implementation and led the work testing the change ideas. PJS and PJ contributed to the delivery of the intervention. PJS and JLD were responsible for data collection. JLD completed the data processing and analysis for assessing the outcome measures interpretation and produced all tables, figure and appendixes. Contributors PJS and PJ prepared the initial draft of the manuscript and played a most significant role in the preparation of the final manuscript. OI acted as a clinical advisor and contributed to the design and implementation of the quality improvement project and revised the final version of the manuscript. PG served as an Improvement advisor and assisted in data analysis. JLD accepts the role of guarantor and takes responsibility for the integrity of the work as a whole from inception to the published paper.

    • Funding The overall quality improvement effort was entirely funded by the Hamad Medical Corporation our parent organisation.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.