A Message From Your President

Happy New Year everyone! Welcome to the winter edition of the TACVPR newsletter, a quarterly newsletter dedicated to delivering the latest information benefiting cardiac and pulmonary rehab professionals. I hope everyone had a good holiday and came back refreshed.

This newsletter contains information regarding the upcoming 2007 TACVPR Conference, Ways to Increase Referrals to Your Program, a Grassroots Campaign Update, Using an Anti-Static Holding Chamber to Improve Medication Delivery in the Pulmonary Patient, and Practice Considerations for the Heart Transplant Patient.

In November, I had the opportunity to represent the Texas affiliate (TACVPR) at the AACVPR Leadership Forum. It was a very insightful meeting and allowed the leadership from each state to have a better understanding of 1) the relationship between AACVPR and each affiliate; 2) resources from the AACVPR available to the affiliates, and 3) a chance to network and share best practices with each of the attendees. The board is also working on plans for the next legislative push for the bills affecting cardiac and pulmonary rehabs. I hope you find this newsletter interesting, helpful and educational…and remember, if you’re interested in writing an article for the next newsletter, please email Kevin Mainz at [email protected]. See you in Austin!

Lorri Lee, BS, ACSM RCEP TACVPR President

It’s Time to Renew Your TACVPR Membership!

Membership dues expired Dec 31 st . To join or renew your TACVPR membership for 2007 you may sign up online or download a printable membership application at www.tacvpr.org

Annual dues are $30/person if paid before February 14 th ($40 after Feb 14 th ).

Winter 2007 Newsletter www.tacvpr.org

TACVPR Conference 2007 Jammin’ in Austin: A Capitol Idea for Rehab

It’s time to start making plans to attend the 2007 annual TACVPR conference. This year the meeting will take place May 4-5 in Austin TX, the Music Capital of the World. Other than being famous for its live music, Austin has many popular attractions within the city, and just a short drive away. Austin will cater to the outdoor enthusiast as well as those more interested in the cultural and historical aspects that the area has to offer. The conference will take place at the Doubletree Hotel located at the intersection of I-35 N. and Highway 290 E. This is a short four mile drive to Austin’s popular 6 www.austintexas.org and www.austin360.com . th St. and a twenty minute drive from Austin Bergstrom Airport. To learn more about the city check out Of course we have a wonderful venue for the meeting. We are fortunate to have Joe Piscatella, a nationally renowned speaker on changing behaviors and increasing health productivity, as a keynote speaker on both Friday and Saturday. We will also have Dr. Mark Millard, Medical Director for Baylor’s Pulmonary Rehabilitation Program, doing talks on Cardiopulmonary Stress Testing, and Hyperinflation in COPD. The breakout sessions will offer educational updates on topics of interest for those working in cardiac and pulmonary rehabilitation, whether you’re a nurse, respiratory therapist, exercise physiologist, physical therapist, occupational therapist, or dietitian. Last year we had an evening social, after the first day of lectures which proved to be very popular. So much so that we have decided to do a repeat performance. Look for the conference brochure in the mail and mark your calendars. There is no better way to network with your colleagues and keep up to date with your profession than attending the yearly conference.

Call for Abstracts & Posters

Do you have a quality improvement project you would like to share with other professionals in the field?

Are you working on a research protocol to improve care for your patients? We would like you to share your knowledge with other programs at the TACVPR Conference in May. For more information about how to submit a poster at the conference please contact Kevin Mainz at [email protected]

Winter 2007 Newsletter www.tacvpr.org

Local Coverage Determination: Draft from TrailBlazer

By: Twyla Selvidge, MS; East Texas Medical Center Regional HealthCare System On October 26, 2006, TrailBlazer issued a draft for an LCD for Cardiac Rehabilitation. Good news! But let’s break this down and see what this really means for us in Cardiac Rehab.

TrailBlazer: the Medicare administrator.

If you have ever traveled on I-635 in central Dallas, you may have seen this tall building with TRAILBLAZER at the top. Lots, bookoos, or kazillions of Texas Medicare beneficiary claims from doctors, hospitals & services like Cardiac Rehab flow through there processing the Medicare claims for either reimbursement to you for your service or denial to you for your service. This is where an LCD can help.

Local Coverage Determination: aka an LCD.

TrailBlazer has never had an LCD for Cardiac Rehab, so this is a first. These are guidelines that we would ‘design’ a Cardiac Rehab program around. The guidelines we currently follow are the CMS National Coverage Policy 20-10. Having an LCD for a specific service, like Cardiac Rehab, makes it easier to interpret the guidelines so you can design just the right program for your patients.

LCD Draft:

You can read the draft for yourself by going to www.trailblazerhealth.com. Then click on Texas on the left sidebar, then click on the accept policy, then click on Draft Local Coverage, then click on Cardiac Rehabilitation C-46AB and you can read the draft for yourself. The public comment period ended on 12/11/2006 and the final policy will be issued in the next TrailBlazer newsletter, which should be due out in February. PLEASE make note of some important changes within this LCD. Time frames for entry into Cardiac Rehab have been affected and in addition, exit criteria has been clarified for the separate entry diagnoses.

The TACVPR will keep you updated on news about this LCD. Winter 2007 Newsletter www.tacvpr.org

Update Your Information for the 2007 TACVPR Directory

We are currently updating the statewide program directory which is available to all current TACVPR members. In order to make sure your facility’s information is included and accurate, please answer the following questions and return this form as soon as possible by email or fax. Hospital/Facility Name:_______________________________________________ Hospital/Facility Address:______________________________________________ __________________________________________________________________ City:_____________________________ Zip Code:_____________________ Department (Cardiac, Pulmonary or both): ________________________________ Department Phone Number: ___________________________________________ Department Fax Number: _____________________________________________ Program Director’s Name: _____________________________________________ Program Director’s Email: _____________________________________________ There is no cost to have your program listed in the directory, but if you do not want your program listed, please let us know. We will let you know when the 2007 directory is completed and available. TACVPR members can view the current directory online at www.tacvpr.org. Thank you for your support, Julie Hartman, M.S.

TACVPR Membership Secretary

Upon completion, please email to [email protected] , fax to 214-820-1412 or mail to: Julie Hartman, MS 411 N. Washington, Suite 3100 Dallas, TX 75246

Winter 2007 Newsletter

Go Red For Women Day is Friday, February 2

nd

www.tacvpr.org

Texas Association of Cardiovascular and Pulmonary Rehabilitation Board Nomination Form

If you are interested in running for the TACVPR board, please complete the form below and send it to Cheri Duncan at [email protected]. You will also need to mail a picture (3x5 or 4x6) of yourself for us to post on a board near conference registration. No scandalous photos please!

Our Question

Name

Your Info

Current Position Location of Residence: City and Region of Texas Education Background including Certifications Current Employer Want to Serve on TACVPR Because Idea on How Best to Help the Members I am interested in serving on and working for the Board of the Texas Association of Cardiovascular and Pulmonary Rehabilitation. I understand the construct and requirements of this Board position and submit my information as nomination for the May 5, 2007, election.

Printed Name: ___________________________________________ Signature: ___________________________________________ (Email will suffice for signature if sent electronically) Winter 2007 Newsletter www.tacvpr.org

Texas Certification Committee Corner

By: Poppy Patterson, RN, BBA Hillcrest Health System

Cardiac & Pulmonary

September 1, 2006 - December 1, 2006

You have already submitted your application and binders if you are applying for Certification this year. Congratulations to those of you who submitted!

December 18, 2006 – March 16, 2007

As a State Committee, we will be reviewing applications. The State Committee may contact you during this time requesting additional information, before the binders are sent to National. We are available to assist you.

April 20-22, 2007

As National Program Certification and Re-Certification Committees, we meet to review all applications. These are full weekend sessions, reviewing hundreds of programs from across the nation.

May 1 – 11, 2007

The National office sends out letters and requests for additional documentation.

May 18-June 22, 2007

Programs must submit additional documentation, as requested.

July 13 – 15, 2007

Once again, the National Program Committees meet. This is for final review, after programs have provided the requested revised documentation from May.

August, 2007

The AACVPR Board of Directors reviews and approves recommendations of National Program Certification and Re-Certification Committee.

August 31, 2007

The National office notifies all programs of final review. This is when you receive your certificate of approved certification!

Re-Certification

The only difference between the Certification and the Re-Certification is the submission deadlines. If you are Re-Certifying your program, the application deadline is:

December 1, 2006 – February 16, 2007

Programs submit applications to National Office on or before. (Must be postmarked by 2/16/07).

If you have questions or need examples, please contact your state committee members. Committee members are listed on the TACVPR website.

See you next Newsletter!

Winter 2007 Newsletter www.tacvpr.org

PRACTICE CONSIDERATIONS FOR THE HEART TRANSPLANT PARTICIPANT

By: Marilyn Burwitz, RN, ETMC Fairfield

In the Fall Newsletter we looked at two of the expanded Medicare diagnoses for

cardiac rehab: PTCA/Stenting and Valve Replacement/Repair. In this article, we will address some of the practice considerations specific to the third diagnosis: Heart or Heart-Lung Transplant.

While there are a limited number of patients who are having heart or heart/lung transplants (only about 3,000 worldwide each year), there is the likelihood that even the smallest program will have such a participant at some point. Some of the things to consider with these participants include: immunosuppressant therapy, rejection, infection, accelerated graft CAD, and abnormal responses to exercise.

Transplant patients are typically treated with immunosuppressant therapy, such as cyclosporine, azathioprine, and prednisone, to prevent acute rejection of the new organ. Some side effects associated with cyclosporine are renal dysfunction, and vasopressor effect (causing hypertension). Some side effects associated with the use of prednisone include: alteration of body fat distribution, mood swings, skeletal muscle atrophy, weakness, osteoporosis and skeletal muscle cramping. Because of the immunosuppressant therapy, the patient is more susceptible to infections. The rehab staff should take precautions to avoid exposing these individuals to active infectious diseases (from staff or fellow participants). You should encourage the transplant patient to wear a surgical mask to decrease the chance of infection.

Accelerated graft CAD may lead to obstructive lesions and is the major limiting factor in long-term survival of the transplant patient. Revascularization may be an option, but because of the diffuse nature of the lesions, oftentimes the only option is retransplantation.

The transplant patient will not have the same response to exercise as seen in the general population. The transplanted heart is denervated at the time of harvest and receives no direct efferent activity from the autonomic nervous system and provides no afferent input to the central nervous system. For this reason, the resting heart rate is usually elevated (>90bpm), the peak heart rate is lower, and the heart rate return-to baseline is delayed, necessitating an extended cool-down period. Ratings of perceived exertion between 11 and 14 should be used to guide exercise training intensity. These participants will also benefit from resistance training that focuses on the legs, back, arms and shoulders. This will help to improve strength deficits that persist after surgery. It also partially restores bone mineral density and addresses the skeletal muscle abnormalities that occur with steroid therapy. For further information on this subject, please refer to the AACVPR Guidelines for Cardiac Rehabilitation and Secondary Preventions Programs and the ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription.

Winter 2007 Newsletter www.tacvpr.org

Using an Anti-Static Holding Chamber with the New HFA Albuterol Metered Dose Inhaler (MDI) Improves Medication Delivery to the Patient

By: Mary Hart, RRT, RCP Baylor University Medical Center The U.S. Food and Drug Administration (FDA) has mandated the removal of the exemption granted to chlorofluorocarbon-based (CFC) albuterol metered-dose inhalers, and the transition to environmentally-friendly hydrofluoroalkane-based (HFA) inhalers by December 31, 2008.

CFCs are man-made hydrocarbons used for decades in products such as refrigerants, foams, solvents, fire extinguishers, and aerosol propellants. Since 1978, CFCs have been removed from almost every product because of the harmful effects CFCs have on the environment by destroying the Earth’s protective ozone layer. HFA quick-relief inhalers differ from CFC inhalers, specifically in taste and spray force. One example is the sensation of the HFA spray will be less forceful than what patients might be accustomed to with the CFC inhalers. Additionally, HFA inhalers must be cleaned in a specific way. With the change from CFCs to HFAs, delivery of the medication is still an issue for patients. With any MDI, making sure the patient receives the desired dose of medication is important. Patient education is a critical factor in the use and misuse of medication inhalers. In a study by Fink, it was found that between 28% and 68% of patients do not use metered-dose inhalers or powder inhalers well enough to benefit from the prescribed medication, and 39-67% of nurses, doctors, and respiratory therapists are unable to adequately describe or perform critical steps for using inhalers. Because of the difficulty in achieving good inhaler technique, holding chambers (HC) are prescribed to address the issue of actuation/inhalation coordination and to remove the ballistic fraction of the MDI aerosol plume, which comprises mainly larger particles that would otherwise deposit on the oropharynx. Holding chambers also retain the finer particles in suspension for some time after inhaler actuation; thus the particles are available to be inhaled.

Even with the use of a holding chamber and its ability to contain the aerosol, delayed inhalation has also been associated with significant loss of medication in laboratory simulation. Manufacturer’s instructions recommend inhaling while actuating the MDI, but many patients have imperfect coordination which can lead to delay between actuation and inhalation from the HC. An important cause of aerosol-particle loss, in addition to the losses associated with gravitational settling, appears to be the adhesion of particles to the HC’s inner surface, caused by electrostatic charge inside the HC. HCs are manufactured from nonconducting materials such as polycarbonate or polyester, which acquire surface electrostatic charge during manufacture and use. The loss of airborne particles caused by electrostatic attraction to the interior surface of an HC is a rapid and continuous process, so the aerosol half-life within the device is significantly reduced. Winter 2007 Newsletter www.tacvpr.org

Using an Anti-Static Holding Chamber with the New HFA Albuterol Metered Dose Inhaler… (cont.)

Recent in-vitro studies have shown that electrostatic charge is more prevalent with some of the new HFA-propelled formulations intended as replacements for CFCs predecessors. Manufacturers therefore generally instruct users to wash and dry HCs before use in order to mitigate charge-related loss of medication. The need to prewash an already clean device complicates its use.

Two new small-volume HCs constructed of electrostatic-charge-dissipative or conducting materials have become available in the United States marketplace. One is the Vortex (PARI Respiratory Equipment) which is manufactured from an electrically conducting and opaque aluminum-bodied chamber, although inhalation-valve operation can be observed through a transparent end-cover. The AeroChamber Max (Monaghan Medical) is a similar-sized, transparent-bodied chamber constructed from proprietary charge-dissipative polymer that allows observation of the aerosol-plume generation and valve operation. Charge-dissipative polymers behave similarly to electrically conductive surfaces and both can be termed “nonelectrostatic”.

In the May 2006, Respiratory Care Journal, Rau et al conducted a study comparing total emitted mass (TEM) and fine-particle mass (FPM) of albuterol (Ventolin HFA) from the Vortex and Aerochamber Max versus 5 HC models of similar size made with nonconductive materials, with and without wash/rinse pretreatment and with 2 second and 5 second inhalation delays. Conclusions of this investigation, which simulated delayed inhalation with HCs, resulted in significantly greater FPM of HFA-albuterol with HCs made from nonelectrostatic materials than from HCs made from nonconductive materials, even after wash/rinse pretreatment. Of the 2 nonelectrostatic HCs tested, the AeroChamber Max delivered more HFA-albuterol in the fine particle size range, irrespective of pretreatment or delay interval. Additional clinical studies are needed to evaluate the importance of these differences with regard to patient outcomes.

After reading the entire study, I have a much better understanding of the different holding chambers on the market and realize “Holding Chambers are not created equally”!

References:

Rau,J, Coppolo,D, Nagel,M, Avvakoumova, V, Doyle,C, Wiersema, J, Mitchell, J.

The Importance of Nonelectronostatic Materials in Holding Chambers for Delivery of Hydrofluoroalkane Albuterol

, Respiratory Care, May, 2006, Vol 51, No 5. pp 503-510.

Fink,J, Rubin,B, Problems with Inhaler Use: A Call for Improved Clinician and Patient Education, Respiratory Care, September 2005 Vol 50 No 10, pp1360 -1375.

Asthma and Allergy Foundation of America. Transition HFA Now, website: www.aafa.org

Winter 2007 Newsletter www.tacvpr.org

10 Ideas to Increase Referrals to Cardiac & Pulmonary Rehab

By: Cindy Serna & Eric Jones, Medical City Dallas Hospital 1) 2) 3) 4) 5) Visit referring doctors' offices and give a folder containing referral forms, brochures about programs offered, diagnoses covered by Medicare, and business card of contact person for your Rehab.

Present outcome information to section meetings of cardiology, pulmonology, internal medicine, and hospitalists. Hand out folders of info.

Present info to medical social workers who are involved in discharge planning. Give folder of info.

Give inservices to Physical Therapy staff to share outpatient programs information.

Distribute brochures throughout the hospital (waiting rooms, kiosks, etc....).

6) 7) Submit short articles, and information in the physicians' newsletter.

Provide inservices to physician offices about services of cardiac and pulmonary rehab.

8) 9) Offer to provide the physicians with tours of your facility.

Involve physicians with any community outreach programs, speaking engagements, seminars, etc. that your department provides. The more they are involved, the more they will remember what a great service you are providing for the patients you see. 10) Provide free cheeseburgers after each rehab session.

Winter 2007 Newsletter www.tacvpr.org

IN OTHER NEWS…

TACVPR Recruit-A-Pal (RAP) Program

Receive points for recruiting other cardiac & pulmonary rehabilitation professionals to join TACVPR and attend conferences. Stay tuned for more information to come.

Writers Wanted

Have you always wanted to write an article in the TACVPR newsletter but didn’t know how? Are you interested in sharing your latest research, patient/program success stories or new guideline updates?

We are looking for members like you to contribute articles for upcoming newsletters. Please email Kevin Mainz at [email protected] for instructions on how to submit an article.

Is Your AACVPR Membership Up to Date?

AACVPR membership dues expired June 30 th – Don’t forget to renew! Membership fees: $150 Member/Associate Member; $75 Student Go to www.aacvpr.org to join or renew your membership.

Job Openings

Medical Center of Arlington is looking for a Cardiac Rehab RN. For more information about this position or to apply please contact Rogina Oquindo at 817-472-4818 or [email protected]. Winter 2007 Newsletter www.tacvpr.org