“Keep Your Move in the Tube” safely increases discharge home following cardiac surgery

Abstract

Background: 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. Objective: 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. Design: Before-and-after study, using propensity score adjustment to account for differences in patient clinical and demographic characteristics, surgery type, and surgeon. Setting: 600-bed acute care hospital. Intervention: 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. Main Outcome Measures: 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. Results: 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 (inhospital 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).

Move in the Tube Sternal Precautions: A Retrospective Analysis of a Single Inpatient Rehabilitation Facility

“…For specific activities, MIT patients were more independent with bed mobility skills and transfers on admission to rehabilitation. Gach (2021) also found that patients on MIT precautions had greater functional mobility on discharge from acute care hospital. 15 Because standard sternal precautions prohibit patients from bending and reaching, patients on these precautions cannot participate in lower-body dressing without first learning how to use adaptive equipment.…”

“…In agreement with other reports, patients adhering to MIT did not experience more sternal disruptions. 7–15 This provides additional evidence that patients adhering to MIT are not at greater risk of sternal disruptions, even within the IRF.…”

“…In their recent publication, Gach et al found patients on MIT precautions were more likely to be discharged home rather than to an IRF or subacute nursing facility. 15 It is possible that this results in more IRF admissions because of medical complications rather than functional mobility needs. Evidence suggests that patients undergoing open cardiac surgeries are older and more complex in more recent years.…”

“…In agreement with other reports, patients adhering to MIT did not experience more sternal disruptions. [7][8][9][10][11][12][13][14][15] This provides additional evidence that patients adhering to MIT are not at greater risk of sternal disruptions, even within the IRF. Patients in the MIT cohort had experienced more complicated surgical interventions and had higher instance of atelectasis and anemia on admission to the IRF as compared with the control cohort.…”

“…5 Less restrictive sternal precautions after median sternotomy have been an active area of research. [5][6][7][8][9][10][11][12][13][14][15] The "Keep Your Move in the Tube" protocol (MIT), developed by Adams et al, instructs patients to move within an imaginary tube when performing mobility and activities of daily living (ADLs). 7,9 This keeps patients' arms closer to their bodies, shortens the lever arm, and minimizes torque/pull on the sternum.…”