Presentation
Keep Your Move in the Tube: An Evaluation of Longitudinal Patient Outcomes and Readiness for Change Amongst Staff
SessionPoster Session 2
DescriptionBackground/Introduction: Traditional sternal precautions following median sternotomy have remained largely unchanged for decades, despite limited evidence supporting their effectiveness and growing concerns about their potential negative impacts on recovery. At Billings Clinic, as at most cardiac surgery centers, patients have historically been instructed to avoid lifting more than 5-10 pounds for 8 weeks, restrict bilateral arm movements, and limit pushing or pulling activities. These restrictions, while intended to protect sternal healing, may delay functional recovery, increase dependence on caregivers, and negatively impact psychological well-being during the critical post-operative period.
In response to emerging evidence suggesting that less restrictive movement guidelines may improve outcomes without compromising safety, Billings Clinic implemented the "Keep Your Move in the Tube" (KYMITT™) protocol on June 3, 2024. This quality improvement initiative represents a fundamental shift in post-sternotomy care philosophy, promoting earlier mobilization while maintaining appropriate sternal protection. The KYMITT™ approach allows patients to move their arms within an imaginary "tube" around their torso, facilitating more natural movement patterns during recovery.
This analysis presents baseline data from the pre-intervention period, establishing critical benchmarks for clinical outcomes, patient well-being, and discharge patterns under traditional restrictive sternal precautions. Understanding the current state of post-sternotomy outcomes is essential for evaluating the impact of practice change and identifying areas where improvement is most needed. This baseline analysis serves multiple purposes: documenting the outcomes achieved with traditional protocols, identifying patient populations who may benefit most from modified precautions, and establishing comparative data for future evaluation of the KYMITT™ intervention. Implementation of the KYMITT™ protocol is expected to yield improvements in patient satisfaction, reduced length of stay, and decreased post-operative pain. Longitudinal follow-up is expected to reveal a faster return to normal activities of daily living compared to the historical cohort managed under traditional restrictive precautions.
Methods: This retrospective analysis examines all adult patients (≥18 years) who underwent cardiovascular surgery with median sternotomy at a large tertiary inpatient facility in the Rocky Mountain West region from June 1 through August 31, 2023, prior to KYMITT™ implementation. The cohort includes patients undergoing coronary artery bypass grafting, valve repair or replacement, and aortic repairs, providing a comprehensive view of the sternotomy population. Patient identification leverages existing clinical registries and workflows. Sternotomy patients are identified through the STS Adult Cardiac Surgery Database, while cardiac rehabilitation participants and their psychometric scores are identified through the AACVPR-Cardiac National Registry. Study variables are then extracted from the electronic health record and compiled for analysis.
Primary outcome measures focus on healthcare utilization and recovery trajectories. Length of stay is calculated from surgery time to discharge order entry in Cerner, capturing both ICU and total hospital days. Discharge disposition categorizes outcomes as home (with or without services), inpatient rehabilitation, skilled nursing facility, or other institutional care, reflecting functional status at discharge. All-cause readmissions within eight weeks are tracked, with specific attention to sternal wound complications, deep sternal infections, and other sternal-related issues requiring rehospitalization.
Secondary measures assess functional and psychological recovery among patients attending cardiac rehabilitation at Billings Clinic, including the SF-36 for health-related quality of life and the PHQ-9 for depression screening, along with pain scores, AM-PAC mobility assessments, and daily activity assessments documented at various time points.
Findings: The pre-intervention cohort included 54 consecutive patients who underwent cardiac surgery with median sternotomy at Billings Clinic between June and August 2023. The mean age was 65.9 years with a median of 68 years (range 24-79). The wide age range reflects diverse indications for cardiac surgery from congenital or early-onset disease to age-related cardiovascular pathology. The cohort showed a gender disparity with 44 males (81.5%) and 10 females (18.5%). Coronary artery bypass grafting (CABG) represented the predominant procedure, performed in 34 patients (63.0%), followed by isolated valve repair or replacement in 11 patients (20.4%). Less common procedures aortic dissection repair (1 patient, 1.9%), and aortic aneurysm repair (1 patient, 1.9%), with 7 patients (13.0%) undergoing other cardiac procedures requiring sternotomy.
Two patients (3.7%) had undergone prior sternotomy; 96.3% were first-time sternotomy patients. This baseline cohort provides comparison data for evaluating outcomes under traditional restrictive sternal precautions before transitioning to the KYMITT™ protocol.
Among the 54 patients, one (1.9%) died during hospitalization following a prolonged stay. For the 53 surviving patients, median length of stay was 6.0 days (IQR 5.0-7.0), with mean 7.9 days (SD 8.1). Discharge disposition demonstrated that 75.9% (n=41) returned directly home, while 16.7% required facility-based care: skilled nursing facility (13.0%, n=7), inpatient rehabilitation (1.9%, n=1), or swing bed (1.9%, n=1). An additional 5.6% (n=3) were discharged home with home health services.
Readmission within 8 weeks occurred in 12 patients (22.2%), with marked variation by procedure type. Valve repair/replacement patients experienced readmission rates of 54.5% (6/11) compared to 14.7% (5/34) among CABG patients. In multivariable logistic regression adjusting for length of stay, CABG was associated with a trend toward reduced readmission risk compared to other procedures, approaching statistical significance (OR=0.32, 95% CI 0.08-1.19, p=0.089). Neither BMI nor weight predicted length of stay (R²<0.02, p>0.30) or readmission risk (OR=1.00, p>0.95), suggesting patient body size does not influence outcomes under traditional restrictive precautions.
Implications: These baseline findings reveal concerning outcomes under traditional restrictive precautions, with nearly one in four patients requiring institutional care or readmission. The striking disparity in readmission rates (54.5% for valve patients versus 14.7% for CABG patients) suggests that current one-size-fits-all movement restrictions may be particularly detrimental to valve surgery recovery. This differential impact, which persists after adjusting for illness severity, indicates that procedure-specific recovery protocols may be warranted.
The comprehensive nature of this baseline assessment, incorporating both traditional clinical outcomes and patient-reported measures, provides a robust foundation for detecting meaningful changes following KYMITT™ implementation. These data also enable identification of patient subgroups who may experience differential benefits from modified precautions, informing targeted implementation strategies and risk stratification approaches.
Analysis: The post-intervention analysis should maintain identical outcome definitions and measurement timepoints to ensure valid comparisons. Statistical analysis should account for potential temporal trends and seasonal variations in outcomes unrelated to the intervention. Subgroup analyses by age, procedure type, and baseline functional status will be essential for understanding differential intervention effects. Additionally, the concurrent staff readiness assessments provide important context for interpreting implementation fidelity and identifying barriers to practice change that may influence outcomes. Future analysis should consider both intention-to-treat and per-protocol approaches, as adherence to new movement guidelines may vary during the early implementation period.
In response to emerging evidence suggesting that less restrictive movement guidelines may improve outcomes without compromising safety, Billings Clinic implemented the "Keep Your Move in the Tube" (KYMITT™) protocol on June 3, 2024. This quality improvement initiative represents a fundamental shift in post-sternotomy care philosophy, promoting earlier mobilization while maintaining appropriate sternal protection. The KYMITT™ approach allows patients to move their arms within an imaginary "tube" around their torso, facilitating more natural movement patterns during recovery.
This analysis presents baseline data from the pre-intervention period, establishing critical benchmarks for clinical outcomes, patient well-being, and discharge patterns under traditional restrictive sternal precautions. Understanding the current state of post-sternotomy outcomes is essential for evaluating the impact of practice change and identifying areas where improvement is most needed. This baseline analysis serves multiple purposes: documenting the outcomes achieved with traditional protocols, identifying patient populations who may benefit most from modified precautions, and establishing comparative data for future evaluation of the KYMITT™ intervention. Implementation of the KYMITT™ protocol is expected to yield improvements in patient satisfaction, reduced length of stay, and decreased post-operative pain. Longitudinal follow-up is expected to reveal a faster return to normal activities of daily living compared to the historical cohort managed under traditional restrictive precautions.
Methods: This retrospective analysis examines all adult patients (≥18 years) who underwent cardiovascular surgery with median sternotomy at a large tertiary inpatient facility in the Rocky Mountain West region from June 1 through August 31, 2023, prior to KYMITT™ implementation. The cohort includes patients undergoing coronary artery bypass grafting, valve repair or replacement, and aortic repairs, providing a comprehensive view of the sternotomy population. Patient identification leverages existing clinical registries and workflows. Sternotomy patients are identified through the STS Adult Cardiac Surgery Database, while cardiac rehabilitation participants and their psychometric scores are identified through the AACVPR-Cardiac National Registry. Study variables are then extracted from the electronic health record and compiled for analysis.
Primary outcome measures focus on healthcare utilization and recovery trajectories. Length of stay is calculated from surgery time to discharge order entry in Cerner, capturing both ICU and total hospital days. Discharge disposition categorizes outcomes as home (with or without services), inpatient rehabilitation, skilled nursing facility, or other institutional care, reflecting functional status at discharge. All-cause readmissions within eight weeks are tracked, with specific attention to sternal wound complications, deep sternal infections, and other sternal-related issues requiring rehospitalization.
Secondary measures assess functional and psychological recovery among patients attending cardiac rehabilitation at Billings Clinic, including the SF-36 for health-related quality of life and the PHQ-9 for depression screening, along with pain scores, AM-PAC mobility assessments, and daily activity assessments documented at various time points.
Findings: The pre-intervention cohort included 54 consecutive patients who underwent cardiac surgery with median sternotomy at Billings Clinic between June and August 2023. The mean age was 65.9 years with a median of 68 years (range 24-79). The wide age range reflects diverse indications for cardiac surgery from congenital or early-onset disease to age-related cardiovascular pathology. The cohort showed a gender disparity with 44 males (81.5%) and 10 females (18.5%). Coronary artery bypass grafting (CABG) represented the predominant procedure, performed in 34 patients (63.0%), followed by isolated valve repair or replacement in 11 patients (20.4%). Less common procedures aortic dissection repair (1 patient, 1.9%), and aortic aneurysm repair (1 patient, 1.9%), with 7 patients (13.0%) undergoing other cardiac procedures requiring sternotomy.
Two patients (3.7%) had undergone prior sternotomy; 96.3% were first-time sternotomy patients. This baseline cohort provides comparison data for evaluating outcomes under traditional restrictive sternal precautions before transitioning to the KYMITT™ protocol.
Among the 54 patients, one (1.9%) died during hospitalization following a prolonged stay. For the 53 surviving patients, median length of stay was 6.0 days (IQR 5.0-7.0), with mean 7.9 days (SD 8.1). Discharge disposition demonstrated that 75.9% (n=41) returned directly home, while 16.7% required facility-based care: skilled nursing facility (13.0%, n=7), inpatient rehabilitation (1.9%, n=1), or swing bed (1.9%, n=1). An additional 5.6% (n=3) were discharged home with home health services.
Readmission within 8 weeks occurred in 12 patients (22.2%), with marked variation by procedure type. Valve repair/replacement patients experienced readmission rates of 54.5% (6/11) compared to 14.7% (5/34) among CABG patients. In multivariable logistic regression adjusting for length of stay, CABG was associated with a trend toward reduced readmission risk compared to other procedures, approaching statistical significance (OR=0.32, 95% CI 0.08-1.19, p=0.089). Neither BMI nor weight predicted length of stay (R²<0.02, p>0.30) or readmission risk (OR=1.00, p>0.95), suggesting patient body size does not influence outcomes under traditional restrictive precautions.
Implications: These baseline findings reveal concerning outcomes under traditional restrictive precautions, with nearly one in four patients requiring institutional care or readmission. The striking disparity in readmission rates (54.5% for valve patients versus 14.7% for CABG patients) suggests that current one-size-fits-all movement restrictions may be particularly detrimental to valve surgery recovery. This differential impact, which persists after adjusting for illness severity, indicates that procedure-specific recovery protocols may be warranted.
The comprehensive nature of this baseline assessment, incorporating both traditional clinical outcomes and patient-reported measures, provides a robust foundation for detecting meaningful changes following KYMITT™ implementation. These data also enable identification of patient subgroups who may experience differential benefits from modified precautions, informing targeted implementation strategies and risk stratification approaches.
Analysis: The post-intervention analysis should maintain identical outcome definitions and measurement timepoints to ensure valid comparisons. Statistical analysis should account for potential temporal trends and seasonal variations in outcomes unrelated to the intervention. Subgroup analyses by age, procedure type, and baseline functional status will be essential for understanding differential intervention effects. Additionally, the concurrent staff readiness assessments provide important context for interpreting implementation fidelity and identifying barriers to practice change that may influence outcomes. Future analysis should consider both intention-to-treat and per-protocol approaches, as adherence to new movement guidelines may vary during the early implementation period.
Event Type
Poster Presentation
TimeTuesday, March 244:45pm - 6:15pm EDT
LocationRhinelander Gallery
Patient Safety Research and Initiatives