The Acute Therapy Department, Memorial Regional Hospital, Hollywood, Florida.
Center for Clinical Effectiveness, Baylor Scott & White Health, Dallas, Texas.
PM R. 2021 Dec;13(12):1321-1330. doi: 10.1002/pmrj.12562. Epub 2021 Mar 22.
Restrictive sternal precautions intended to prevent cardiac surgery patients from damaging healing sternotomies lack supporting evidence and may decrease independence and increase postacute care utilization. Data regarding the impact of alternative approaches on safety and outcomes are needed to guide evidence-based best practices.
To examine whether an approach allowing greater freedom during activities of daily living than permitted under commonly used restrictive sternal precautions can safely decrease postacute care utilization.
Before-and-after study, using propensity score adjustment to account for differences in patient clinical and demographic characteristics, surgery type, and surgeon.
600-bed acute care hospital.
Beginning March 2016, the acute care hospital replaced traditional weight- and time-based precautions given to patients who underwent median sternotomy with the "Keep Your Move in the Tube" (KMIT) approach for mindfully performing movements involved in the activities of daily living, guided by pain.
The study compared sternal wound complications, discharge disposition, 30-day readmission, and functional status between consecutive cardiac surgery patients with "independent" or "modified independent" preoperative functional status who underwent median sternotomy in the 1.5 years before (n = 627, standard precautions group) and after (n = 477, KMIT group) KMIT implementation.
The odds of discharge to home, versus to inpatient rehabilitation or skilled nursing facility, were ~3 times higher for KMIT than standard precautions patients (risk-adjusted odds ratio [rOR], 95% confidence interval [CI] = 2.90, 1.95-4.32, and 3.03, 1.57-5.86, respectively). KMIT patients also had significantly higher odds of demonstrating "independent" or "modified independent" functional status on final inpatient physical therapy treatment for bed mobility (rOR, 95% CI = 7.51, 5.48-10.30) and transfers (rOR, 95% CI = 3.40, 2.62-4.42). No significant difference was observed in sternal wound complications (in-hospital or causing readmission) (rOR, 95% CI = 1.27, 0.52-3.09) or all-cause 30-day readmissions (rOR, 95% CI = 0.55, 0.23-1.33).
KMIT increases discharge-to-home for cardiac surgery patients without increasing risk for adverse events and reducing utilization of expensive institutional postacute care.
旨在防止心脏手术患者损坏愈合胸骨切开术的限制性胸骨预防措施缺乏支持证据，并且可能会降低独立性并增加急性后期护理的利用。需要关于替代方法对安全性和结果的影响的数据，以指导基于证据的最佳实践。
研究一种方法，该方法在日常生活活动中比常用的限制性胸骨预防措施允许的活动自由度更大，是否可以安全地减少急性后期护理的利用。
在使用倾向评分调整以考虑患者的临床和人口统计学特征、手术类型和外科医生差异的情况下，进行前后研究。
600 张病床的急性护理医院。
自 2016 年 3 月起，急性护理医院用“保持活动在管内”（KMIT）方法替代了接受正中胸骨切开术的患者的传统体重和时间为基础的预防措施，该方法在疼痛的指导下，以正念方式进行日常生活活动中涉及的运动。
在接受正中胸骨切开术的连续心脏手术患者中，比较胸骨伤口并发症、出院去向、30 天再入院和功能状态，这些患者在 KMIT 实施前 1.5 年（n=627，标准预防组）和 KMIT 实施后（n=477，KMIT 组）具有“独立”或“改良独立”术前功能状态。
KMIT 患者出院回家的可能性是标准预防患者的 3 倍以上（风险调整后的优势比[OR]，95%置信区间[CI]分别为 2.90，1.95-4.32 和 3.03，1.57-5.86），而入住康复医院或熟练护理设施的可能性较小。KMIT 患者在最终住院物理治疗治疗床上移动（OR，95%CI 分别为 7.51，5.48-10.30）和转移（OR，95%CI 分别为 3.40，2.62-4.42）方面，表现出“独立”或“改良独立”功能状态的可能性也明显更高。胸骨伤口并发症（院内或导致再入院）（OR，95%CI 分别为 1.27，0.52-3.09）或所有原因的 30 天再入院率（OR，95%CI 分别为 0.55，0.23-1.33）无显著差异。
KMIT 增加了心脏手术患者的出院回家率，而不会增加不良事件的风险，并减少昂贵的机构急性后期护理的利用。
