Table 2

Cardiac Rehabilitation/Secondary Prevention Performance Measurement Set B-1

Performance Measure B-1
B-1. Structure-Based Measurement Set
The cardiac rehabilitation/secondary prevention (CR) program has policies in place to demonstrate that:
1. A physician-director is responsible for the oversight of CR program policies and procedures and ensures that policies and procedures are consistent with evidence-based guidelines, safety standards, and regulatory standards (43). This includes appropriate policies and procedures for the provision of alternative CR program services, such as home-based CR.
2. An emergency response team is immediately available to respond to medical emergencies (44).
A. In a hospital setting, physician supervision is presumed to be met when services are performed on hospital premises (45).
B. In the setting of a free-standing outpatient CR program (owned/operated by a hospital, but not located on the main campus), a physician-directed emergency response team must be present and immediately available to respond to emergencies.
C. In the setting of a physician-directed clinic or practice, a physician-directed emergency response team must be present and immediately available to respond to emergencies.
3. All professional staff have successfully completed the National Cognitive and Skills examination in accordance with the AHA curriculum for basic life support (BLS) with at least one staff member present who has completed the National Cognitive and Skills examination in accordance with the AHA curriculum for advanced cardiac life support (ACLS) and has met state and hospital or facility medico-legal requirements for defibrillation and other related practices (43,46,47).
4. Functional emergency resuscitation equipment and supplies for handling cardiovascular emergencies are immediately available in the exercise area (44).
NumeratorThe number of CR programs in the health care system that meet these structure-based performance measure criteria
DenominatorAll CR programs within a health care system
Period of AssessmentPer reporting year
Method of ReportingInclusive data collection tracking sheet
Sources of DataWritten program policies
Rationale
The delivery of CR services is physician-directed and provided by a multidisciplinary staff of health care professionals. A system for communication between a physician-director with expertise in CVD management and a referring or primary physician enhances the program's success in helping that patient achieve individualized target goals. It is the responsibility of the physician-director to assure that the information and instruction given to patients in CR is consistent with the most current clinical practice guidelines.
There is a growing trend among patients referred to and completing early outpatient CR to be older, at higher risk, and have more chronic comorbidities (48). Medical supervision is the most important day-to-day safety factor in CR (43). Personnel and equipment for ACLS are essential to the adequate delivery of emergency care for patients who experience cardiac arrest or other life-threatening events during CR sessions.
Although rare, cardiovascular emergencies can occur during exercise training in CR programs. Studies suggest that the incidence of cardiac arrest requiring defibrillation is approximately 1 arrest every 100,000 patient-hours (49). Practice guidelines for management of cardiac arrest include the use of BLS and ACLS strategies, such as early defibrillation (17,43). Such strategies have been shown to help improve outcomes in persons who experience cardiac arrest (50).
Some CR programs seek certification of their program by health care organizations, such as AACVPR, in order to show that they meet certain standards for the delivery of CR services. Such a certification process, while outside the scope of this document, may result in documentation of a program's ability to meet this (B-1) and other CR performance measures mentioned in this document. Currently, for instance, CR program certification through AACVPR requires that all of the above policies (Items 1 to 4 above) are in place and operational.
Corresponding Guidelines and Clinical Recommendations
Medical Director Responsibilities for Outpatient Cardiac Rehabilitation/Secondary Prevention Programs (43)
(No class of recommendation or level of evidence given)
There is a physician-director responsible for program oversight and to ensure that policies and procedures are consistent with evidence-based guidelines, safety standards, and regulatory standards.
AACVPR Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs (51)
(No class of recommendation or level of evidence given)
All professional staff have completed BLS training; at least 1 staff member is present who has successfully completed training in ACLS.
Medical supervision for moderate- to high-risk patients will be provided by a physician, registered nurse, or other appropriately trained staff member who has successfully completed AHA curriculum for ACLS and has met state and hospital or facility medico-legal requirements for defibrillation and other related practices.
Exercise Standards for Testing and Training: A Statement for Health Professionals From the American Heart Association. AHA Scientific Statement (52)
(No class of recommendation or level of evidence given)
An emergency response team is immediately available to respond to medical emergencies.
CMS National Coverage Determination for Cardiac Rehabilitation Programs (45)
(No class of recommendation or level of evidence given)
Functional emergency resuscitation equipment and supplies for handling cardiovascular emergencies are immediately available in the exercise area.
Challenges to Implementation
Adherence to this measure requires the engagement of a physician-director who is accountable for policy development and implementation.

Reprinted, with permission, from Thomas et al. (15). All references within this table are from Thomas et al. (15).