SM

Ch 14: Management of Medical Problems and Emergencies

Overview of Chapter 14

Chapter 14 of the guidelines focuses on the management of medical problems and emergencies within Cardiopulmonary Rehabilitation (CR) and Secondary Prevention (SP) programs, led by Dr. Lisa Kappes. This chapter highlights the critical role these services play in ensuring patient safety during exercise by anticipating potential emergencies and preparing appropriate intervention strategies.

Objectives and Importance

The chapter's primary objectives include:

  • Describing responses to urgent and emergent medical situations in CR/SP.

  • Outlining procedures for assessment and screening to identify potential problems.

  • Detailing medical intervention procedures for emergencies, including the use of emergency equipment and pre-established protocols.

  • Specifying training requirements for staff to ensure they are equipped to manage emergencies effectively.

Safety in CR/SP Programs

Research indicates that CR/SP programs have a very low incidence of life-threatening complications. Specific statistics reveal the rate of complications during exercise include:

  • Cardiac arrest: 1 per 116,906 patient-hours

  • Myocardial infarction: 1 per 219,970 patient-hours

  • Fatalities: 1 per 752,365 patient-hours

  • Major complications: 1 per 81,670 patient-hours
    Despite thorough initial screenings, the chapter emphasizes the unpreventable nature of some complications during exercise sessions as higher-risk patients increasingly enter rehabilitation.

Advance Directives

Advance directives are vital documents prepared by patients to outline their healthcare preferences when they cannot communicate their wishes. The common forms include:

  • Living Wills: Plans created by the patient beforehand.

  • Durable Power of Attorney: Appoints someone to make financial and healthcare decisions on behalf of the patient.

  • Health Care Proxy: Identifies a person responsible for healthcare decisions when the patient is unable to make them.

Do Not Resuscitate (DNR) Orders

The chapter clarifies that a DNR order signifies that resuscitation is not desired but does not imply a refusal of treatment. Patients with DNR should continue to receive comfort and care.

Patient Assessment and Screening

Staff must carefully observe each patient’s condition during exercise, being trained to recognize symptoms that signal potential emergencies. Key areas to monitor before exercise include:

  • Recent medical history

  • Heart rate and rhythm

  • Blood pressure

  • Body weight

  • Oxygen saturation (SPO2) levels

  • Compliance with medications

Documentation of angina symptoms, dysrhythmias, and additional clinical signs such as syncope (fainting) or exercise intolerance is crucial for effective intervention.

Angina and Ischemia Monitoring

Multiple factors related to chest discomfort must be documented including:

  • Quality, quantity, frequency, triggers (like exertion or emotional stress).

  • Any associated symptoms during exercise, with a clear record of the point at which these symptoms arise to guide future sessions.

Handling of Hypoglycemia and Hyperglycemia

Monitoring blood glucose levels is essential, especially for diabetic patients. Blood glucose should be maintained above 100 mg/dL during exercise, with specific precautions based on the diabetic type:

  • For Type 1 diabetics, exercise is not advised at levels above 300 mg/dL.

  • Ensure availability of glucose monitoring devices and carbohydrate sources.

Depression and Psychological Screening

Depression can significantly impact recovery and heart health. Screening at entry is recommended, and continuous monitoring is essential for adjusting care and treatment based on changes in mental health status.

Emergency Protocols and Interventions

During exercise, CR/SP personnel must be alert for clinical emergencies, implementing interventions based on assessment outcomes. Interventions may include:

  • Modifying or stopping exercise

  • Patient positioning for comfort

  • Vital sign monitoring

  • Administering oxygen or medications such as nitroglycerin or glucose

Documenting emergencies and interventions accurately is paramount for continuity of care and risk management.

Staff Training and Emergency Preparedness

Training and preparedness are critical components of emergency management in healthcare settings. The chapter specifies:

  • Mandatory completion of training evaluations based on AHA standards for BLS and ACLS.

  • Regularly scheduled drills to practice emergency responses and equipment checks.

Equipment Requirements

Emergency equipment must be readily accessible during CR/SP activities, including:

  • Automated External Defibrillators (AEDs)

  • Portable oxygen systems

  • Emergency medications and supplies.

Community and Home-Based CR Programs

Addressing home-based rehabilitation, the chapter stresses the need for emergency preparedness in non-traditional settings. Family members must also be educated on CPR and emergency procedures to ensure timely response in critical situations.

Summary

The chapter concludes that the continuous assessment and preparation to manage emergencies are essential for CR/SP services. Having structured protocols and well-prepared personnel can significantly enhance patient safety and outcomes during rehabilitation activities, particularly for those at higher risk of cardiac incidents.