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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 2  |  Page : 146-150

Impact of coronary artery bypass graft on activities of daily living of patients with coronary artery disease: A comparative study using the extended nursing care model


1 MGM New Bombay College of Nursing, Maharashtra, India
2 MGM Medical College and Hospital, MGM Institute of Health Sciences, (Deemed to be University), Sector- 1, Kamothe, Navi Mumbai-410209, Maharashtra, India
3 MGM College of Nursing, MGM Institute of Health Sciences, (Deemed to be University), N6, CIDCO, Aurangabad- 431003, Maharashtra, India
4 Department of Cardiothoracic Surgery (Adult), Fortis Health Care Ltd., Mulund, Goregaon Link Rd, Bhandup West, Mumbai-400078, Maharashtra, India

Date of Submission01-Feb-2021
Date of Acceptance05-Apr-2021
Date of Web Publication02-Jun-2021

Correspondence Address:
Dr. Jyoti Milind Chaudhari
MGM New Bombay College of Nursing, MGM Institute of Health Sciences, (Deemed to be University), Sector 1, Kamothe, Navi Mumbai 410209, Maharashtra.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mgmj.mgmj_8_21

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  Abstract 

Background: When it comes to a major surgery such as Coronary Artery Bypass Graft (CABG), functional independence is the ultimate goal of treatment over mere survival or drastic reduction in the risk of the life-threatening event caused due to Coronary Artery Diseases (CAD). Objective: To find the difference in the ability to perform Activities of Daily Living (ADL) before and after the CABG between control and study groups who received conventional methods and who received nursing care by using the Extended Nursing Care Model (ENCM), respectively. Materials and Methods: Data were obtained from 132 patients before CABG and after six weeks and three months of CABG. Patients were enrolled on the day before surgery and included those who were discharged only within seven days of surgery. The lottery method was used on a weekly basis for allocation of the patients in the control and study groups. The study group’s recovery was managed by using ENCM, and the control group’s recovery was managed by using the conventional method. Functional independence in performing ADL was measured by using a standardized Barthel scale. Data were also collected on developing independence in performing the bathing activity. Results: The majority of patients’ mobility-walking and staircase use activities were affected before CABG. The mean score of the functional independence has improved from baseline to six weeks and three months in both the groups. The difference in the functional independence score between the two groups was tested by using the Mann-Whitney’s sign-rank test. The improvement was found to be better in the study group than the control group at a 5% significance level at six weeks and three months after CABG. Conclusion: The researcher concludes that though functional independence is compromised in the initial stage of recovery of CABG, it improves over some time and this improvement can accelerate with the use of interventions in the ENCM.

Keywords: Activities of daily living, bathing, coronary artery bypass graft, coronary artery diseases, extended nursing care model, functional independence, nurse-led intervention


How to cite this article:
Chaudhari JM, Pani S, Mhaske A, Mulay A. Impact of coronary artery bypass graft on activities of daily living of patients with coronary artery disease: A comparative study using the extended nursing care model. MGM J Med Sci 2021;8:146-50

How to cite this URL:
Chaudhari JM, Pani S, Mhaske A, Mulay A. Impact of coronary artery bypass graft on activities of daily living of patients with coronary artery disease: A comparative study using the extended nursing care model. MGM J Med Sci [serial online] 2021 [cited 2021 Sep 20];8:146-50. Available from: http://www.mgmjms.com/text.asp?2021/8/2/146/317452




  Introduction Top


Coronary artery disease (CAD) leads to a decreased flow of blood to cardiac muscles and its exhaustion. Insufficiency of oxygen slows down the pumping of the blood to other parts of the body, resulting in symptoms of dyspnea and/or cardiac pain, which is enough to disturb activities of daily living (ADL). The patients get ready for the treatment when it starts disturbing ADL or when they are frightened about limited ADL in the future or related death. Medication, intervention cardiology, or coronary artery bypass graft (CABG) surgery are the available treatment options.[1] However, surgical interventions such as CABG drastically decrease the risk of death due to CAD, which causes a decrease in the functional ability of patients for few days to weeks,[2],[3] having an association with preop health status.[4]

This makes sense that irrespective of CAD treatment, the outcome should be a level of independence or ease in performing ADL and the absence of symptoms such as dyspnea and cardiac pain.[5] This study aims at comparing the functional independence of patients in performing ADL before and after CABG, surgical intervention in two groups: The control group received the conventional method of discharge and recovery management, and the study group received Extended Nursing Care (ENC) interventions in addition to the conventional method of discharge.

Hypothesis

There is no difference in the functional independence score of the patients with CABG in the study group and control group at the end of 1½ months and three months of surgery.


  Materials and methods Top


A total of 140 patients with CAD who underwent CABG were selected purposively from Fortis Health Care Limited: a Super Speciality Hospital, Mumbai, Maharashtra, India, over one year. After clearance from the ethical review committee and obtaining consent from the patients, the patients with CABG younger than 75 years of age were asked to rate their functional ability by using the Barthel Index (BI) standardized scale[6] before the decision of surgery and after six weeks and three months of surgery. These patients were enrolled equally into two groups by using a weekly lottery method on the day of discharge.

With six patients lost to follow-up, one death, and one withdrawal, at the end of the study, there were only 69 patients from the study group and 63 patients from the control group who could sustain till three months of the recovery period CABG. The control group received a conventional method of discharge, which includes regular discharge instructions, routine three follow-up services with a helpline number. The study group received care during the recovery period by using the ENCM. The model consisted of a set of interventions such as supervision, reinforcement, encouragement, reassurance, and environmental modification on the day of discharge; at home on the 3rd, 10th day of discharge; and at the OPD at six weeks and 12 weeks, in addition to the conventional method. The focus of the ENC intervention was to assess and address the needs and problems of patient participants with CABG during the first three months of the recovery period. The ADL progression plan was an integral part of discharge instructions in both the groups.

Here, the ADL is limited to feeding, bathing, grooming, dressing, continence of bowel and bladder, toilet use, moving from a bed to chair and return, mobility on a level surface, and climbing of stairs up and down. Scores of each of the items were added to obtain a total BI score. The total score ranges from 0 to 20. The 0 level of score indicates a higher level of dependence or inability to perform the task. The level of functional independence in ADL was assessed before, as well as after six and 12 weeks of CABG. The patient participants with CABG received the score based on the level of help required to perform the earlier mentioned ADL. The BI score was compared at different time intervals.


  Results Top


The mean age of the participants who underwent CABG was 59.78 ± 7.22 years in the control group and 61.96 ± 7.51 years in the study group. Males constituted a higher percentage in the control group (77.8%) as well as in the study group (88.4%). The majority of patients with CAD who underwent CABG were diagnosed with Triple Vessel Disease (TVD) (74.6% in the control group and 78.3% in the study group). The majority were operated without using a cardiopulmonary pump or off-pump techniques. The type of conduit used was a saphenous vein graft (SVG), radial artery (RA), and internal mammary artery (IMA); in a few patients, the conduit was taken from more than one site.

No difference was found at a 5% significance level in age, gender, and education of patients with CABG in the control group and the study group.

Comparison of participants’ Barthel Index obtained at different time intervals in each group

The mobility-walking and staircase use were the most commonly affected ADL among all 10 functional ADL of participants before CABG, which was improved at six weeks and three months in the control group as well as in the study group [Table 1].
Table 1: Distribution of participants based on functional assessment score

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Functional independence

The ability of participants in carrying out ADL based on the Functional Independence assessment, BI has increased over the period after CABG in the control group as well as the study group [Table 1] and [Figure 1].
Figure 1: A cluster column-line Combo graph showing the timeline distribution of the mean of functional independence score of participants in the control and study groups

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Mean-rank differences in functional independence score illustrated in [Table 2] show that there was no significant difference in the functional independence score of participants of the control and study group before surgery as P = 0.214. It means that both groups were comparable at a 5% significance level. At 6 weeks and at 3 months of the recovery process, the functional independence score of participants was statistically higher than the control group at P = 0.007 (z = −2.680) and at P = 0.029 (z = −2.183), respectively.
Table 2: Mean-rank differences in functional independence score at a different time interval and test statistics

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It has been observed that there was a decline in the mean functional independence score of female patients with CABG in both the study and the control group at six weeks and this improved over the 12th week [Table 3].
Table 3: Distribution of mean Barthel Index score based on age group and gender

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Comparison of independence in bathing activity

Bathing was one of the key activities that was observed to gather functional independence in both the study and control groups based on the previous study. It shows that 84.1% of study group participants developed independence in bathing activity by 4 weeks of recovery compared with 38.1% in the control group [Table 4].
Table 4: Distribution of participants based on the time of bathing independently

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There was no association of age, gender with independence in bathing activity in the control group as well as in the study group. A higher number of patients with CABG gaining independence in bathing in the study group by the fourth week of recovery shows the effectiveness of ENCM, especially the environmental modification intervention carried out under ENCM [Table 5].
Table 5: Statistical table showing an association between bathing independently and age, and gender

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  Discussion Top


In the present study, an improvement was found in functional independence measured by the BI, as the mean baseline score was lower than the mean score at six weeks and 12 weeks in both the groups [Table 2]. This reiterates the fact that CAD leads to poor functional ability, which improves after CABG surgery.

The mean functional independence score has significantly improved over a three-month recovery period in both the control group (from baseline mean 19 to 19.2 at 6 weeks and then 19.7 at 3 months) and the study group (from baseline mean 19.04 to 19.62 and 19.91 at 3 months), with higher significance in the study group [Figure 1]. The higher percentage of patients with CABG gaining independence in ADL, such as bathing earlier than 4 weeks of discharge, was indicative of the impact of ENC on early normalcy to life among the study groups. The researcher has neither found a study where bathing activity was used as a parameter to assess functional independence.

This confirms the effectiveness of ENCM on the improvement of functional independence of the patients with CABG, especially in the first 6 weeks of recovery.

Marcassa et al. conducted a cohort study to analyze the recovery from disability after cardiac surgery and to assess the long-term effects of residual disability. The data were obtained from 5261 patients on the day of admission to the rehabilitation program prospectively and on the day of discharge from the same by using the BI scale. The researcher has categorized the participants based on the grades of the disability as severe, moderate, mild, and no disability. After cardiac rehabilitation, 75.1% of patients with severe disabilities improved their functional status, with an associated 50% reduction in mortality at the 5-year follow-up. Though there was an improvement in the overcoming of disability after the rehabilitation program, it has diluted the result of the rehabilitation program. The BI was the major predictor of survival and hospitalizations at the follow-up. The present findings of the study are limited to three months of the recovery program. Nevertheless, findings have shown a similar trend of improvement at BI among the patients in the study group.[7]

It may be observed from [Table 3] that the baseline mean BI score among the study group participants has increased to 19.9 scores, irrespective of the age group. However, among the control group, a better rise in the mean BI score has been observed in the age group younger than 60 years compared with that older than 60 years. This shows significant improvement in the elderly of the study group over the control group. A similar improvement over functional independence after CABG in the elderly has also been reported by other researchers.[8]


  Conclusion Top


The study reveals that CABG improves the functional status of patients and they regain their normalcy of life. It may also be improved at an early stage by using an ENCM.

Acknowledgment

A special word of appreciation must go to the authorities of Fortis Hospital, Mumbai, India for allowing the authors to carry out the study in their hospital after seeking ethical permission. The author is exceedingly grateful to The Maryland State Medical Society, Baltimore, Maryland, the United States for making available the Barthel ADL scale, free of cost, for carrying out the study.

Financial support and sponsorship

MGMIHS.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kaul U, Bhatia V Perspective on coronary interventions & cardiac surgeries in india. Indian J Med Res 2010;132:543-8.  Back to cited text no. 1
    
2.
LaPier TK, Wintz G, Holmes W, Cartmell E, Hartl S, Kostoff N, et al. Analysis of activities of daily living performance in patients recovering from coronary artery bypass surgery. Phys Occup Therapy Geriatr 2008;27:16-35.  Back to cited text no. 2
    
3.
Chaudhari J, Pani S, Mulay A, Mhaske A Need of nursing interventions for CABG patients after discharge. Nursing J India 2016;107:248-51.  Back to cited text no. 3
    
4.
Direk F, Celik SS, Lefkoşa KK Postoperative problems experienced by patients undergoing coronary artery bypass graft surgery and their self-care ability after discharge. Turkish J Thorac Cardiovasc Surg2012;20:530-5.  Back to cited text no. 4
    
5.
McNamara RL, Spatz ES, Kelley TA, Stowell CJ, Beltrame J, Heidenreich P, et al. Standardized outcome measurement for patients with coronary artery disease: Consensus from the International Consortium for Health Outcomes Measurement (ICHOM). J Am Heart Assoc 2015;4:e001767. doi: 10.1161/JAHA.115.001767.  Back to cited text no. 5
    
6.
Barthel DW Barthel index for Activities of Daily Living (ADL). Available from: https://www.mdcalc.com/barthel-index-activities-daily-living-adl [last accessed on 2020 December 8].  Back to cited text no. 6
    
7.
Marcassa C, Giordano A, Giannuzzi P Five-year hospitalisations and survival in patients admitted to inpatient cardiac rehabilitation after cardiac surgery. Eur J Prev Cardiol 2016;23:1609-17.  Back to cited text no. 7
    
8.
Niemeyer-Guimarães M, Cendoroglo MS, Almada-Filho CM Course of functional status in elderly patients after coronary artery bypass surgery: 6-month follow up. Geriatr Gerontol Int 2016;16:737-46.  Back to cited text no. 8
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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