It could be Socratic. OK. Hopefully, you can all hear me. If everyone came to the very front row, I wouldn't have to scream or shout. But don't worry about it. You're fine where you are. My definition of success of a presentation is we have at least as many people in the audience as we do on the panel. And I think we've done that. So I really appreciate it. It is interesting, though, how important and valuable this is. And yet, we don't get the room filled with people. That being said, there are some other great courses going on. We do appreciate you being here. I'm going to assume that you are involved with or want to be involved with transplant rehabilitation. We're going to focus today on heart and lung rehabilitation. But I think it can be fed over into other areas, including kidney and liver and even bone marrow, et cetera. So number one, welcome. Number two, cell phones, please, down. And number three, keep the conversation to a minimum. You'd probably have to shout to each other across the way. But because it is being recorded, do fill out your evaluation forms, please. We appreciate that. The pavilion is still open. Don't forget to go. I think there's another sandwich coming for the Lunch and Learn, so that's a good enticement. It certainly gets me there. We have four faculty. Just very quickly, we're going to start with Dr. Karen Barr, who's going to be talking about optimizing patients for heart and lung transplant. Dr. Barr is an associate professor in the Department of PM&R at the University of Pittsburgh, UPMC, with a specialty practice focused in lung transplant rehabilitation, which is why we invited her, of course. Actually, I'm going to say, we both put this on together. We are co-session directors. And the reason I'm going to say that is because we spoke. We wanted two hour and 15 minute sessions. We got squeezed down to one. We had to leave off some faculty, which was a shame. But there's a broader picture. Dr. Kerry DeLuca is going to be talking about frailty assessments for people going for heart and lung transplants. And Dr. DeLuca is an assistant professor in the Department of PM&R, medical director of the UPMC Rehabilitation Network, and director of the PM&R Consultation Service at PUHMUH. Presbyterian and Montefiore. Thank you. Presbyterian and Montefiore for the microphone. Last, and by no means least, Dr. Matthew Bartels is going to be talking about outpatient cardiac rehab and pulmonary rehab for heart and lung transplant patients. Dr. Bartels is the chair of Rehabilitation Medicine and professor of PM&R in the Department of PM&R at Albert Einstein College of Medicine and specializes in cardiac and pulmonary rehab. I will introduce myself briefly when I give my talks, but I'm going to be giving two. One is on early mobilization and inpatient rehab for heart and lung transplants. And the other is metrics that support your program. I will just say that transplant is obviously growing. There's a tremendous need for rehabilitation throughout the continuum of care. And that's why we put this on, because of the growing volume of patients pre-peri and post-transplant. And we are essential for their management and optimization. Without much more ado, Dr. Bartels. Thank you. So as we mentioned, we're going to be really crossing the spectrum. and that every patient should be evaluated for. So, uh, as you likely know, frailty is a complex interplay of aging... And so, of course, an organ transplant. We also know it's dynamic, so when you measure frailty at different points in time, you're gonna get something different. And we know that it's somewhat modifiable by prehabilitation techniques and also by the organ transplant itself, but it's not completely modifiable. So there's many mechanisms that have been theorized as the reason why frailty is so prevalent in transplant patients. So for both heart and lung transplants, about a third of patients, depending on how you measure it, are considered frail at the time of presentation for transplant. So part of it is the organ itself. So for example, in lungs, hypoxia is bad for your muscles, particularly your proximal thigh muscles. But there's also sort of many other factors and inflammation is thought to unify many of these reasons why people. for your metabolism, and so that's why we see such wide-ranging effects that result in the clinical picture of frailty and inflammation. The COPD patient's main symptom is breathlessness. So they have breathlessness, and then they decrease their activity, and then they get deconditioned, and then they get more breathless, and then they decrease their activity, so it's a cycle. And we see something very similar with our heart patients. risk factors that are associated with frailty. Frailty is a concept and so we look at how deconditioning or was it European rather, Respiratory Society, had a statement on looking at frailty assessments in. which you probably know about because you're British, but the rest of us, I was like, what in the world is that? So I looked it up, and it seems like it's more of a European concept than an American, but it looks a lot like PM&R. So this is a picture from a paper that was a meta-analysis of the effectiveness of these comprehensive assessments, and then it looked at what factors in different programs made up a comprehensive assessment. And so it's the sort of things that we do, right? So there's gotta be a clinical leader, a structured assessment, you work on a multidisciplinary team, you involve patients and caregivers, you have follow-up, you have enough time to do it, you have specialty knowledge. It sounds a lot like what we do. So I like to think of my frailty assessments, I love to cook, sort of like cooking. So there's many ways to make a good stew, right? There's lots of ingredients. You can have a really good stew that the meat is the basis, you could make a really good stew, and pumpkin is the basis, and both would be very valid. And so I think the data that we bring into frailty assessments can be very diverse, and then it's really up to sort of the chef to bring these ingredients together. And anybody who's ever, has anyone here ever gotten a recipe from their mother, made it, and it didn't taste right at all? So that's, the cook matters, right? And I think it's like that in frailty assessment. Our expertise, our knowledge, our perspective. process, we try to classify patients based on risks of poor outcome to inform the selection committee. So I think it's very important that frailty itself is such a dynamic, vague concept that we could never deny someone an organ transplant just based on frailty. So we really try to present what is the risk for this individual at this time, identify risk factors, create a plan, and then create an individualized program. So some places will have like a prehabilitation program and it might be like 12 weeks. You join the program and you do the 12 weeks. We don't do that. We really sort of think, how much time do we have to get this ready for transplant? How can we come up with a program that fits this person and works with their caregivers that it could actually be implemented? And we know that social determinants of health influence every step of the transplant. from our transplant center. rural Pennsylvania. in exercise history, and then I'm. test of lower extremity function, looks at balance, normal gait speed at 4 miles an hour. And this is a measure that's very widely used in the lung transplant literature. It's also used in hearts. And one of the landmark studies was done by. increase risk of death with transplant and every point you do worse on that test from 12 on down it's a near linear relationship with poor outcomes about 10 to 20 percent per point so we know this is associated with other poor outcomes beside death so never that they're frail or not frail but remember it's a linear relationship right so every point that you So I go to the selection meeting and I sort of present the patient with the SPPB, but also with their other factors. grip strength, BMI, really looking for clues of adiposity. So we know in lung transplant, central So we know BMI only tells a little piece of that because our prehabilitation plan, and it works. So the mainstay of that is cardiac and pulmonary rehab. You guys know that's a structured program of a series of visits that's individualized, but patients exercise in a group, and it improves frailty. do very well with PT, hoping that we have enough time to then get them into pulmonary or cardiac rehab, or if they've already had pulmonary and cardiac rehab but they haven't made it the gains or they've had a functional decline, we get them in for a focal strength. anxiety and depression. Anxiety, a huge problem in the lung transplants, and depression a huge problem in the heart patients. So we work on those. And then pain and smoking are common risk factors for having heart and lung disease. And so we see a lot of people with musculoskeletal pain problems. And some of these patients, that holds them back just as much as their end organ dysfunction, and so addressing that. So this is one of my favorite quotes. It's from Eleanor Roosevelt. I feel like this is what So I'll leave you with a couple pearls. I know you know our program they love to do transplants. They would wish that every patient I think it really uses a diverse skill group and I enjoy that so I get to use my musculoskeletal skills. We try to get our residents to come through clinic, which is not always successful, but there is a unique. Hoxia, exercising with cardiac meds, and those sorts of areas of expertise. So thank you very much. Thank you. Therapists were very familiar with this concept of doing frailty evaluations, even before we started having meetings with them. And, excuse me. group together, why do they care? elements that we saw, and I'll have another slide showing that, as well as a cognitive assessment. So we added a MOCA to our assessment. So we were thinking about what kind of measurements needed to be done, who would be collecting this data, where they would put it, and then one of the residents working on our team, Dr. Cromer, very kindly created a pre-completed consult note. So we have a note that has areas where we're going to input all this data. Sadly it doesn't pull it automatically, but the pre-completed note has all the areas where we put in the data for the SPPB and the FREED. It also brings in all those questions that we ask as part of our questionnaire that have to do with prior function, current function, you know, mood, those types of things. So this is just one example of sort of the FREED frailty phenotype. So the five areas are, that you're assessing, are exhaustion, grip strength or strength in general, mobility, appetite, and physical activity. So we do have a standard questionnaire that we use that addresses some of these issues. So for instance, the questions about exhaustion or the questions about physical activity come right from our interview with the patients. Grip strength is measured by our occupational therapist. Mobility, we use the results from our four-meter walk test from the SPPB to answer that question about mobility. And then appetite, we do have questionnaires or questions that we ask during our interview, but also every patient is assessed by a nutritionist as part of their evaluation. So in terms of bringing in all the stakeholders, our physical therapists were extremely helpful. They are the people who assess the SPPB and get that data for us. I will say that patients need to be able to... need to be physically able to participate. So some of our patients, honestly, their medical acuity is too high to participate. Sometimes by the time we're seeing the patient, they already have impella devices in place. Sometimes it's things that you might not even think about. So one time we had a gentleman who had such severe scrotal edema he couldn't stand up. So he just couldn't do these elements of the test. And then one time we had a gentleman who was ICD fired. Every time he sort of stressed himself and he's like, there is no way I'm doing five times sit to stand because my ICD is going to go off and there's no way I'm doing that. So, you know, we as physiatrists sort of look at the whole picture and then as we do these evaluations, we very honestly explain, if we can't get the data, this is why we can't get the data. So again, our physical therapists were really, really helpful in getting this data for us. And also the physical therapy leadership is very helpful in training therapists because it's not as though we could have one or two therapists who specialize in this. We needed therapists to be able to be doing these seven days a week because patients aren't always available, you know, during weekdays. And certainly the way our flow works, if they put a consult in on Friday, I need our therapists to be able to get this data over the weekend so that we can put it together for the consult team and get their answers by their Monday 1 o'clock meeting. So Dr. Barr already showed the SPPB. So we're just measuring three different domains. So balance, gait speed and the sit to stands. And 12 is the highest score. And just for our patient population... Sorry, let me go back. For our patient population, frailty is a score less than seven on the SPPB. So when we're rating this in the heart population, it's a little different than the lung population. And so for OT, we were also very lucky to have wonderful OT leadership working with us to get this up off the ground. The OTs measure grip strength and they do the MOCA assessment for us. And so you're all familiar with grip strength. And so strength is, you know, you know, listed and you can see in the table according to the norms or according to age and gender. And then this is what it looks like in our EMR. So we use Cerner PowerChart for now and we have outcome sections. So our therapists know that they're going to put this data in the outcome section and we know to look for it there. So it all makes it very straightforward. I wish it automatically loaded into our consults, but it doesn't, but maybe someday it will. That would be great. And so in thinking about this, you know, who is ordering these evaluations, managing expectations, right? So usually when we get a consult, we want to have that done within 24 hours of when we get it. But it's just not possible. In most cases, it's not possible. And we as the PM and our consult team, we understand the flow of how things work with the therapists. So if our cardiology consult or our cardiology colleagues put in a consult for OT and PT at 9 a.m., my therapists are not going to see that because they've already had their plan for the day. They already know what they're going to be doing. So we have our phone numbers for all the therapists across the hospital. I'll give them a call and say, by the way, there's a new consult for Mr. Jones for frailty eval. If you have bandwidth today, could you by any chance try to see the patient and get that evaluation done? And they're wonderful. Our therapists really try very hard to get these things done and if they can't get it done today, they're going to try really hard to get it done tomorrow. So, you know, knowing that we have a little bit of leeway. Dr. Barr was also very instrumental in talking to the heart transplant team in the beginning and say, look, we're not going to be able to get these done the same day. Like we just realistically can't get it done, but we do try very hard. We know they meet at Monday at 1 p.m. and we really try our best to get these evaluations done. And sometimes if our note is not going to maybe be done by them, we'll just call them up. If there's a limitation, we'll call them up. We have really good communication and obviously we're discussing things with cardiology attendings, fellows. Outpatient coordinators are the ones who put the orders in, but really we're dealing more on the inpatient side. So, as I mentioned before, we had wonderful help from PT and OT leadership and, you know, they really helped us with the rollout and they went so far as, you know, there was a difficulty in the beginning with how the therapists were seeing the orders. So the orders were being put in in one way and our therapists weren't seeing them. And so PT leadership really drove changes to the order set so that the orders could be seen in a timely manner and these evaluations could be done. So in terms of what we do as the consult team, we review the EMR, we interview the patient and of course we're very focused on function. So we want to know what the patient was doing prior to their exacerbation of heart failure. We want to know what they're doing now. And we've honestly seen a range of activity levels in our patients. We see patients who are in-house but walking the hallways and doing very well and they're going to be sent home but we're finishing this evaluation in-house. Then we obviously have people at the other end of the spectrum who are extremely critically ill and, you know, maybe we can't even get our frailty assessment completed because they're not able to participate because of their medical acuity. And so as I mentioned, when we do a physical exam when we see the patient, as I mentioned we use the Freed Frailty Index. It's a modified Freed phenotype and we use the MOCA and the SPPB. And we make that assessment. So do we think the patient is not frail, pre-frail or frail? It's very easy I think when the patient clearly is one end of the spectrum or the other, right? So they're clearly not frail. They're very actually robust and that's an easy assessment. Or the other end of the spectrum, like they're clearly really, really frail. I think the times where that patient is in between, maybe they score pre-frail on one measurement and frail on the other or, you know, somehow they're in the middle. It's where our knowledge as a physiatrist really comes in handy to sort of paint the whole picture, look at the whole picture. And we were very encouraged early on by Dr. Barr telling us, you know, this is just one piece of the puzzle. This is not going to make or break whether they're accepted for a transplant, but it is really important information that the team wants. So in terms of lessons learned... Is that you? In terms of lessons learned, obviously we all know how important it is to work as a team in PM&R communication and being flexible. And I don't think I told the story. So when this all got off the ground, our start date was November 1st of last year. We were all gearing up. Therapy was gearing up. We were gearing up. We're getting all ready. And the first consult came in on October 27th, which was a Friday afternoon. And so, you know, it was kind of... We just all chuckled like, okay, we're going to work hard on this, but, you know, we kind of knew going into it. We have to be a little bit flexible. So we did have some hurdles early on. We did try to adapt as best as we could. And really, again, as physiatrists, doing that assessment when your data is incomplete, talking with the cardiology team, letting them know... The gentleman I mentioned with the scrotal edema, I said, okay, well, are you all going to diuresim? And the cardiology fellow said, well, his right side and heart pressures are really low. We really can't diuresim aggressively. And so it's really kind of an interesting back and forth. He eventually did have... He was able to complete the assessment a few weeks later. And then in terms of identifying areas to improve function, we know that when we think about frailty in our cardiac patients, our heart failure patients, we know that there's data to show that there's an element of this that's reversible. So we want to identify factors that can be... That we can do interventions for that are going to help these patients. So in the domains of exercise, nutrition, I mentioned, all the patients are seen by nutrition service. And then psychological, most of our patients, all of them are seen by supportive and palliative care as part of the comprehensive evaluation. And many of them are seen by our psychiatry service as well. But we as physiatrists do play a role in identifying things, identifying elements in the frailty eval, you know, in which we are elements that we can intervene about. Sorry for the bad grammar, but you know what I mean. Alright. Thank you very much. The little... It's the hook. I'm setting my own hook too. I'm Jonathan Weitz and I'm one of the... physiatrists at Rusk Rehabilitation and I'm the medical director of the Cardiac and Pulmonary Rehab Program. And let me skip through these. I'm going to be talking about the inpatient rehab for patients going through heart and lung transplant and especially focusing on some key areas. I have nothing to disclose. We're going to talk about early mobilization programs. We're going to be talking about the value of inpatient rehab, strategies for enhancing throughput, readmission production, and successful discharge to the community, which is always a challenge in these populations. And then metrics, which I'll probably leave to my second talk, which is on metrics. So let's focus on the first area, which is early mobilization. And this is a trend that PM&R should be absolutely involved with if not be running early mobilization programs. We'll first talk about from Johns Hopkins, Dale Needham published a lot of data back 15 years ago looking at the value of early mobilization programs and we were certainly early adopters of that at NYU. I'm going to be talking about that in a moment, but you cannot have an early mobilization program if you don't have PM&R physician involvement. So as Kerry was saying, you need a PM&R consult service and a consult service is just not a filtration service to get patients into the inpatient setting, but a consult service really is comprehensive and should be involved in programmatic development in the acute care setting as well as doing specialty consults at the bedside to deal with the specialty issues that we, PM&R physicians, are the most expert at taking care of and coordinating. Yes, we can be involved with disposition planning. Maybe that's to home, not to IRF or SNF, but we're the ideal ones to be able to understand and integrate functional evaluations into that. And then of course if patients are going to go straight home from the hospital, how do we get them into the outpatient setting rapidly? How can we work on that? And without a doubt, we need data because if we don't have data, no one's going to put money behind this initiative. No one's going to support your faculty in the acute care setting or give you the therapist that you need, et cetera. And we should be publishing as well. This data is very valuable and we should be sharing it. So what was our experience before we initiated our early mobilization program back to... We put our program in 2017. So we noticed that patients were staying in the ICU for a very long period of time and they were sedated and because if they weren't sedated, they were a little delirious or they were in too much pain. So it was always best to keep them quiet. They were sedated by the teams and you can't mobilize a sedated patient. And there was mayhem. There was no coordination. Nobody took responsibility. Nobody ran. Everyone came in to do their own separate consults. And the care culture was let's help them survive through the ICU. What happens afterwards? Not that we don't care, but we're not in touch with that. And executive leadership of the hospital weren't involved. So it was not the best situation. So we said, okay, we need a collaborative team and we need the physiatrist to run that team and the PM&R team to be significantly involved. We needed to address sedation and delirium and sleep-wake cycles and pain so that when our therapists went by, when our physicians went by, patients were awake. Patients were controlled in terms of their pain. They weren't delirious. We needed to change the culture. Yes, it is important what happens down the road. Early mobilization. We needed to have this culture that we could get patients out of bed and mobilize safely with no matter what tubes and lines and pumps and ECMOs, et cetera, that they had, we can mobilize them safely. And we needed support from executive leadership in the shape of dollars. And these were our outcomes from our pilot program. We had a significant reduction in ICU length of stay, in hospital length of stay. Direct costs went down. Discharge to home went up. Discharge to home without services went up. The need for post-acute care went down. And we saved money. This is the kind of data that you need to implement and support your early mobilization program. And we did publish this. So Dale Needham's work is published. Our work is published. There are other centers that have published work as well. That's Dale Needham's reference. So not only did we do that for our broad cardiac pulmonary patients, but we did it as well just more recently in 2023 for our heart and lung transplant patients. Surprise, surprise, same data. Reduced length of stay, better discharge to home, better outcomes, lower costs. So what does it look like when we're talking about an enhanced rehabilitation program? So for our patients in the ICU and beyond into the sort of the step-down units and the surgical units, our therapists will see patients twice a day, seven days a week. That's a requirement. That's a given. That's our standard of care. They'll get daily occupational therapy and they'll get daily speech language therapy as well, depending on... and with the transplant patients, with the transplant patients, especially the lung transplant patients, there's a lot of dysphagia and a lot of dysphonia as well. And they get regular follow-up by our consulting physiatrists, two to three times a week at least if they see the patients every single day. We encourage that if they're making a difference, if they're giving the information to the therapist and to the team in terms of the optimal management. Most of our heart transplant patients will go home. Well, excuse me, 50% of our heart transplant patients will go home from the acute care setting, but the majority of our lung transplant patients will come onto our inpatient rehabilitation facility. So what does that look like? What about inpatient rehab? Well, it's the same as inpatient rehab for any program in terms of the requirements, but there's no doubt that these patients with heart and lung transplants have very significant needs in terms of medical care. They need the transplant team to round daily. It's a given. They must be there to take care of those issues. And as physiatrists and rehabilitation teams, we need to be aware of what the early complications are. What can go wrong? If we're bringing patients in within a week or two of transplant, what could go wrong in that time? Bleeding episodes, pericardial effusions and constriction, rejection episodes, stroke, infection, graft dysfunction, sternal infection. You need to be aware of that in the heart transplant patients and in the lung transplant patients. Similar. Again, bleeding issues, pleural issues, venous and arterial thrombosis, nerve damage, recurrent laryngeal, phrenic nerve, and vagal nerve issues are all not uncommon. And we're the site where we're going to be diagnosing these, noticing these, and taking care of them. So what are the requirements? As I said, three hours plus, 15 hours plus a week, a multidisciplinary team. Psychology is essential. We have nursing, social work, and case management. These patients are not easy to discharge. We need a lot of case management that starts in the acute care setting and goes into the inpatient rehabilitation setting. And a significant focus on education. Patients and family members are essential to smooth the discharge. Length of stay, relatively short, seven to 14 days for these patients, and a coordination to rapid outpatient settings. So some key focus areas. Again, throughput. So our experience was that patients spent a long time in the acute care setting and we couldn't get them into the inpatient rehabilitation setting quickly. The transplant teams initially didn't quite understand what we could take care of from a medical perspective. The consulting clinicians, our physicians were not following... Oh, excuse me, the consulting transplant team weren't following the patients on a daily basis on our unit. There was a lot of mismatch in terms of the needs and the understanding of what was needed. So we worked on communication in terms of medical issues. We worked on education of the heart transplant and lung transplant teams. We told them that we could take care of the VADs and the inotropes. We could take patients and do bronchoscopies and myocardial biopsies from our unit. We would accept all of that. And we made sure that for the transplant teams and the services that supported the transplant teams, endocrinology and GI and everyone who was needed, we put in electronic consult orders for them to help make them accountable and come and see their patients in a timely experience. Readmission reduction from our inpatient rehab facility back to the acute care setting and from patients who've been discharged home back to the hospital setting. Significant readmission issues and I'll show you some data in a minute. But again, we were taking patients very early. We were taking very complex patients. What was the solution? How could we address this significant readmission issue? Again, that daily transplant team rounding on our rehab unit, treating in place. Again, we didn't want to discharge a patient for a bronchoscopy and a myocardial biopsy. We did it from our floor. We took patients with chest tubes. We managed arrhythmias, atrial fibrillation, which is one of the most common arrhythmias. We managed them on our floor so we wouldn't have to readmit them. And we educated the rapid response team. The rapid response team gets called at the weekend or at nighttime and if they didn't know that we wanted to manage the patients on our floor, the first thing that would happen, they'd be discharged off. So we had to educate them as well. What about discharging patients to home? So again, very difficult when you have a relatively short length of stay. You're admitting patients early. You want to get them home and we found a lot of patients were being discharged to skilled nursing facilities and we needed to pay attention to that. So again, communicating with the acute care teams on optimizing their medical management, you know, working with in the acute care setting even before patients came over to the inpatient rehab center to make sure that patients and families were aware of the rehab process and the need to go home and what they were going to be expected to do in terms of wound care and medication management. As needed, we increased our length of stay on our inpatient rehab facility. If we felt that two or three more days of stay at the rehab center would get the patient home, that's what we did and we also made sure that we fast tracked our patients into the outpatient setting and we set a goal. We said 75% of our patients are going to go home. We've actually exceeded that. We're now at 80% of our patients, but we needed to be cognizant of all of this. Transitional care management, if you're not aware of what transitional care management is, it's once patients go home, it's an enhanced program of care for 30 days once a patient has gone home, which includes an evaluation by a nurse and an evaluation by a physician within those 30 days and it's essentially advanced care management as well as making sure that home services are in place, medications are being taken and there's an enhanced payment as well, a reimbursement for the physician, but it's significantly associated with readmission reduction. So we've instituted a transitional care management program that is for every single one of our patients who leave our transplant unit and it has made a difference, a significant difference. Metrics. When I come back up here the next time, I'm going to be discussing them, but we have metrics that help us understand how we're doing in terms of early mobilization in the intensive care setting, how we're doing in terms of inpatient rehabilitation, how are we impacting throughput of our patients, reducing readmission and getting patients to home. So again, those were my objectives. I hope I've covered all the points. I will come back up here in a few minutes after Dr. Vartels has spoken in order to talk about those metrics and how you can follow them and justify your program. Thank you. Alrighty. You're doing good. So far. Alright. So thank you guys. This is going to be interesting, because this is where I get to go and talk about the easiest part potentially, but it is actually not the easiest part, because as you've heard from Dr. Whiteson and from everybody else who spoke, these patients often have readmission. There's a lot of other issues and we're talking the long-term outcomes. So disclosures, nothing really pertinent to this talk. I'm going to talk a little bit about the specifics of what we talk for cardiopulmonary rehabilitation, both for the cardiac and for the pulmonary patients. It's a little bit of a tall task of 13 minutes to cover both, but we'll do it. Talk a little bit about what we look for in our patient evaluation. Some of the things, a little bit about prescription writing, and then also the growth potential for us with working out for making better outcomes for these patients in the long-term. So how did I get started in this? I think the personal experience is actually a very important part of why this is here important. I was involved in early mobilization even before Dale Needham and everything there, because we had a lung volume reduction program at Columbia. So in 1998, we were already involved in this. So I date myself a little bit there. But I actually was involved in cardiac and pulmonary rehab, and I found that the pulmonary patients and the complex cardiac patients were, excuse me, were interesting. Standard cardiac post-bypass, things like that. They were pretty formulaic, not as interesting. And they had a lot of complications and a lot of very ill patients with a lot of issues that needed to be addressed that physiatry clearly was in a position to be able to address. So it started working with interventions in the cardiac ICU, on decubitin and pulmonary emboli. They were actually having episodes where patients effectively, they were on bypass pumps and other kinds of things like this, were actually having cranial decubitin. So they were clearly not moving the patients enough, and I actually lost it. And they asked me why. I said, because I'm going to be managing the damn decubitus six months from now. You guys don't know I hate managing decubitin. So it was a personal thing. I did not want to see these patients anymore. I was also working with the ICU team, being a hound on the nurses. And that actually helped, because they then respected that we actually had some input, but also the teams respected that we were decreasing some of their very significant complications. And also be willing to take on these patients for the phase 1B, or for the inpatient rehab unit, and take some of the heat from our own inpatient team, because it was like, oh, there's another Bartels bomber coming in. Yes, indeed. But as I would tell them, this is the only time you can do a life-saving rehab, because for these pre-transplant patients, I know I'm supposed to talk post, but for the pre-transplant patients, this was an opportunity to see if somebody could actually get listed and maybe get a transplant. That was life-saving. If it didn't work, the quality of life would markedly improve, as Dr. Barr had pointed out. So talking briefly about this, the physiology of the post-cardiac transplant patient at rest is something that has to be considered in your outpatient program design. I'm not going to belabor this, but they all have resting tachycardia, because they don't have vagal innervation of the heart, and they have a very delayed response to exercise, so that they don't actually get as high a heart rate, and it takes a long time. So that means long warm-ups, long cool-downs, and educating the patient that they don't have a broken heart, because many of the patients are very heart-conscious, and in the excitement and all the other things that are going on, they may not have either heard or been told that their heart will not respond the way a heart normally does to exercise, physiologic stimulus, and psychological stimulus. There's also a decrease in stroke volume, and this is all associated with a little bit of increased myocardial fibrosis, because of the preservation process that they actually undergo. Another thing that you may also see is increased sensitivity to plasma catecholamines, because that's the only thing that they respond to. So it's an onset of epinephrine, increases their heart rate, and the adrenaline goes down. It takes a long time to go down, but they become more sensitized, because it's the only thing their body responds to. Diastolic dysfunction, once again with the myocardial stiffness. All of these are things to consider in that outpatient prescription writing. They have a near-normal resting cardiac output, so they look pretty good when you do an echocardiogram, but that doesn't mean that they have a normal exercise response. And they have an increased AVO2 difference, which means that they're actually still having to be more efficient to get the same amount of exercise, because the cardiac output at maximum is not as high. So that we talked about, the late onset of increased heart rate, you have lower maximal heart rate, slower recovery, and a lower maximal cardiac output, which means that that efficiency that they had in that heart failure state pre-transplant is still necessary. Won't belabor this, just because of the fact that we have time. Now, post-lung transplant, because I have to get to those guys too. They're my favorite peeps. They have a decreased ELCO. That's the diffusion capacity of the lung for carbon monoxide, which is a way, yes, we give carbon monoxide to patients with pulmonary disease. It's very little bit. But it's a way for us to measure how readily oxygen can traverse the membranes. And it is not 100% normal, even post-transplant, because once again, preservation and the explantation implantation process does cause some fibrosis and damage to the lungs. It's very close to normal, but it's not 100% there. So there is a little bit of decreased ability for that. You also have lack of autonomic innervation to the lungs, just like to the heart. So they don't bronchodilate, and they don't bronchoconstrict the same way that other patients do. So some of these patients may actually still benefit from bronchodilators post-transplant to help them achieve maximal exercise, because they don't have the sympathetic innervation that causes that normal bronchodilatation. Resting hypertension, true in the heart and in the lung. Heart transplant patients, you might kind of anticipate you're going to monitor more closely. But in heart transplant patients, you have the same thing. It's the effect of the transplant rejection medications. A lot of steroids, yes, but the steroids usually go down within the first six months. It's the calcineurin inhibitors that cause the majority of these problems. And they can actually, if unfortunately you have to be on these medications, it can lead to renal failure in a certain number of these patients. And there's also that lower maximal exercise output from both the cardiac effects, from the effects of the ability to breathe, and also with the scarring that you get in your chest wall, your total lung capacity is also decreased, because you do have scarring even from a clamshell incision. So you are going to have some decreased ability to actually exercise to what you think they should be able to do. But normal or near normal pulmonary functions. They have the saturation is usually pretty good, despite the DLCO limitation. There's also a problem of the decrease in maximal ventilation that we talked about. Now, biggest problem is that their muscles are not normal. So we talked a lot and heard a lot about frailty. If you cannot put in that improvement in muscle before, you're going to have a really bad time after. Because the muscles are not normal. Why? Because of the medications. Well, first off, you're on up to a gram and a half of solumedrol a day when you first get your transplant. That's not good for you. A lot of our lung patients have been on chronic steroids for years, like our COPD patients. So they come in with really, really bad sarcopenia. And my problem with the pre-transplant patients is often that they're cachectic. It's not the obesity. It's just they've got nothing. They've got no fat mass and no muscle mass. So these are patients who are very frail going in, and then coming out, you're thinking, oh, now we can actually exercise them. They have pretty normal lung capacity, but the problem is, or have a heart failure patient in similar state. Now they've got a pretty decent cardiac output, but the problem is they've all these medications. And what do they do? It's the calcineurin inhibitors that are to blame. There's been really great research in basic science that shows in mice, you know, we could cure anything in mice, and also in rabbits, that the calcineurin inhibitors decrease all of the things that we want to do with muscle growth. It decreases stem cell differentiation. Yes, we have stem cells in our muscles that when we exercise will actually differentiate and give you the ability to increase your muscle mass. They decrease fiber type switching. Many of our patients are type 2x fiber, which is a really survivable fiber, but it doesn't really function terribly well. But it will survive in a hypoxic environment, like the lung patients, or in a low flow environment, like our heart failure patients. You need to switch those fibers to type 2a's or to type 1's, whatever you're actually training for, but it can't do it as well. It's markedly inhibited by the calcineurin inhibitors. And the other thing that it does is it decreases the ability for other adaptations. All of this is related to why it's such a good transplant rejection medication. It doesn't allow immune cells to differentiate and to also become large clonal expansions. So that's what it really is, why we're using it, but it does the same thing to the GI system. But for us as physiatrists, it's the problem of what it does to our peripheral muscles. So my observation is it takes two times as long to gain muscle strength. And I've had patients that were marathon runners before, and they try to train, and they can't get ... With all the training techniques, and they know how to do this, they cannot get back to where they were. They have like nine minute miles, and that's the best they can do. And they're very frustrated. They've got good cardiac and lung function, and they just can't get better than that. They can't get to the six or five minute miles they did before their lung or heart disease. So this is something that is a real factor that you've got to deal with. So medications and transplant, I'm going to do a real fast thing. It's the calcineurins you've got to worry about. They're cytotoxic agents. The corticosteroids is another big one. And then you have these anti-lymphocyte antibodies and other things that are used for acute rejections. They cause a lot of acute problems in our outpatient settings. So a patient who has an acute rejection episode goes and gets treated, comes back out, they're going to be weak as a kitten. So you feel like you've lost everything. But that's where we're really important. Cyclone, big thing that you've got to worry about with this is leukoencephalopathy. Often will present as they're starting to have nondescript, weird neurologic symptoms. You're like, I think the guy's got MS. Think leukoencephalopathy. Tacrolimus, the big thing you're going to get with that is tremor. OT is definitely needed for this because you can't take the medication away. So you're going to have to work around it. Some of these patients get converted to sirolimus and some other medications, but the problem is that you really want to keep the calcineurins in there. Not going to spend because of time going through all of this, but the slides are there for those who are interested in it. Now orthopedic complications, osteoporosis. A lot of them have it. Now you're starting to exercise them. Worry about stress fractures. We do see those on occasion. There's also muscular weakness and arthritis and back pain as was mentioned. Neurologic issues. Peripheral neuropathy and tremors are the biggest ones that I've seen. You do get, later on, CNS lymphomas. Lymphoma is a complication of the immunosuppressive regimen. So if you start seeing weird symptoms, think this may be a true central neurological syndrome. And then as I mentioned, renal failure is a big problem long term in a lot of our patients on top of, of course, graft rejection. Psychologically, depression, anxiety, sexual dysfunction. All of these are things that you need to attend to in your patients. A lot of the patients are very anxious about resuming sexual activity or doing other kinds of activities. So this is a place where you can actually help them by really reassurance and showing them that they can do various activities. So Dr. Weitzen had already talked about how it's really important to do that post-surgical mobilization and then transfer them to the outpatient. Running out of time in a moment, but the thing that we're going to talk about here is what do you need in the program? You need space because you need to distance these patients from other people. They're immunocompromised. You need accessibility, geographical and physical. I am hoping that the tele-rehab services that we had during COVID will come back because those were excellent because that also gives us the longitudinal care. And a good home program like basically putting them on their own Peloton program is a way to maintain function. And with the idea they need twice as long to gain strength can allow for us to do this. Support groups are critical for both family and patients. PTSD is a big problem. If you've seen your relative for two months in the ICU pre-transplant and then a rocky course and three re-ops and so forth, the families are traumatized. They also need help. And then the maintenance program. Do something for maintenance and I think the virtual programs will be great for us. And I'm telling myself that I'm over. So basically, conclusion is you need to think of doing the post-discharge rehab. Get them in your outpatient cardiac and pulmonary rehab programs. They're well suited to do this and often they may know the patients from before. Fight, fight, fight to get the insurance coverage for your lung transplants post-transplant because often they used up all of their benefit. You know, you only get 36 lifetime, whatever. There's a lot of limitations that are stupid in the insurance companies. They're evil. Just fight them. The other thing is assess the quality of your local rehab services. Patients don't want to travel back to the mothership if they live 100 miles upstate New York. Know what the resources are locally so that you can get them into those programs. And then think to treat your patients. Don't think when they're discharged home they're all good and sweet. There's so much that needs to be restored. Thank you guys. Let me try to squeeze a lot in in a short period of time. That's why we wanted, you know, two hours and a half, but still this is what we got. A wise person once told me that brain injury rehab is forever. It's lifelong. I'm going to say the same with regards to transplant rehab. And we see our patients lifelong. They don't live forever, but they have needs throughout their lifespan and we're always there for them. So I'm going to talk to you now about metrics. And if you don't have metrics, you don't have a program. So you need metrics, you need to gather your data, and you need to show value. And we are so valuable to the health system. The triple aim, the quadruple aim, for the sake of time I'm not going to go into detail, but you've heard this terminology, and PM and our physicians are essential to this process. Click your ruby red heels, where do we all want to be? Dorothy said it, we want to be home. And that's our goal. That's what we're trying to do, getting patients out of the acute care setting, getting them home as soon as possible into outpatient services. That's the value we bring. We have to prove it through our data. So let's look at some of our data in the acute hospital, in the inpatient setting, and in the outpatient setting. I hope you've heard of observed to expected length of stay. That's what your chief executive officers and your executive leadership are looking at. How long are patients staying in their acute care hospital setting, the observed? And what's the expected? It's a calculation that comes back to them weeks or months later, but if it doesn't look good, as in this ratio is over one for patients that are going to your rehab setting, they're going to come to you and they're going to scream and shout and pull their hair out until you get it right. So this was us. Yes, it wasn't a screaming and shouting, it was a discussion. It was right-sizing the therapy services, right-sizing the consult services, but you can see that reduction in observed to expected length of stay. These are our transplant patients that went on to our transplant service from fiscal year 2021 over the past four years, successfully going down below one. Essential. Early immobilization programs, I showed you the data. They make a difference. Again, here's the data. Reducing length of stay in the ICU, reducing length of stay in the hospital, reducing costs, getting patients home sooner, and rather than going to an inpatient rehab facility and saving money. Your executive leadership, your C-suite, love this data. You probably have it in your setting. If you don't use ours or use Needham's or use Matt's, whoever's, use the data, show that there's value. Again, not just for all the heart and lung patients, but for the transplant patients as well. I've shown you that data already. Physician productivity, consult services. You need to be cognizant of how many consults your team is seeing. In fiscal year 24, we saw 194 consults on the transplant. This is just heart and lung transplants. Close to 200, that volume is growing. We set a target of seeing our patients within 16 hours. These are our physicians, 16 hours, seven days a week, no matter what. We're not doing bad, 77% in the last year. Our goal is 80%. It's not 100%, but we're doing okay. What about in the inpatient rehab facility, your inpatient rehab unit? Occupancy. If you're getting close to 90%, that's good. There's always a reason. Sometimes we don't have all private rooms. We have a lot of double rooms. As Matt says, sometimes these patients need to be isolated. We have a 22 bedded unit. We may have 11 patients and that's 100% occupancy because every other bed is blocked. 90% is really good. Administrators want to see that. Length of stay, keep an eye on it. Sometimes we're keeping people a little bit longer, but anywhere between 12 and 14 days is our average. 60% rule, yes. All of these patients, they have myopathies and neuropathies and encephalopathies. Don't say delirium. It doesn't count in terms of 60%. You've got to say toxic or metabolic encephalopathy. Document it, you're treating it, and that helps you with the 60% rule. That's our unit that has our heart and lung patients, so not bad, close to 50%. Our other units, which we're all considered together, help us. This year, fiscal year up to September, I think it was at 76% or 74% overall, and we keep an eye on our compliance with the 60% rule. We think it's ridiculous, but we all have to do it. We have to live in that. Complicated patients have complications. We need to know. We need to follow it. This is our trend. Some ups and downs. We never like any complications. I don't know why they made C. diff, the brown color, but you could probably put two and two together, and the yellow color is catheter-associated urinary infections. They're being smart here, being really funny, but you need to know what's going on with your patients. These are our complications on our transplant rehab unit. You need to know what they are. You need to make sure you've got best practices. You need to make sure you're working with the nursing education teams, because they have a lot to do with central line and catheter-associated infections, C. diff policies. All of these things need to be followed, but you must know so you can be accountable and you can discuss it with your executive leadership team. 30-day readmissions. We were doing relatively well until fiscal year 22, and a slight increase in readmissions, both from our inpatient unit and from... Excuse me, both... Yeah, from the unit back to the hospital and once patients have gone home. Our heart and lung transplant patients, fiscal year 23, 42.6% readmission rate. This is high, but these are a complex group of patients. We can't hide... We can't hide the data. We have to understand it. We have to explain it. We have to discuss it. We have to put in remediation processes, like I say, treat in place, do the biopsies from our unit, manage the arrhythmias there, have the transplant teams monitoring and rounding, and we were able to make a difference. Every time we see bad data, we look at it, we internalize it, we reinvigorate our efforts, and we were able to get our numbers down by about 5%. We need to know why patients are being readmitted. Transplant complications, sepsis, infection, et cetera. You need to know why so you can address those. You can look for them. Be the canary in the coal mine. The earlier you see something, the sooner you can make a difference. What we did do, though, what we did find was we looked back through our data that we were actually admitting our patients three days earlier on average from one fiscal year to the other. So from fiscal year 23 to fiscal year 24, the length of stay, the actual length of stay in the acute care hospital went down three days. In conjunction with our readmission reductions, that's sort of a double plus, not the double whammy, the double plus. And that makes a difference as well. Every patient we can bring over a few days earlier, which means that the hospital can backfill. When it comes to the CEO and the executive leadership, they're looking at, oh, dollars and cents. Yeah, we look at patients and well-being and outcome, but they want to make sure that things are fiscally sound. Bringing patients over sooner makes a difference. This is data for our inpatient unit. Value added, yes. Are we profitable? So yes, the gray is the profit. Yeah, it gets a little smaller as we go to fiscal year 24. The expenses versus the income, you see that. The blue is the... I need your reading glasses now. Yeah, the inpatient revenue versus the inpatient direct expenses. So why is the revenue looks good, so why is that number going down? That's the indirects and it's the cost of labor as well. So all of this comes in to show, again, you need to be able to explain it because the question will come up, oh, look at the overall profit and loss. As long as you can explain it and discuss it and understand where it's coming from, you're on more solid ground. So transitional care management, as I said to you, and it's a central program in readmission reduction. Look at this data. The orange or whatever color that is, those are the patients, our patients who went home from our transplant unit who got a transitional care management program who were involved. It's really only for Medicare patients. We do it for all of our patients, but there are logistical issues. Most of these visits are virtual visits and some of our patients don't know how to do the virtual visits, so some of them just cannot do this visit. But the difference is striking. The blue is the readmission rate for those patients who did not get that transitional care management program versus the orange. It really makes a difference. It's very valuable. We were talking about, as well as cardiac rehab and pulmonary rehab, what about the general rehab therapies? These are my numbers. How many patients am I sending to outpatient physical and occupational therapy? Why is that important? Well, I need to show my value to the department. How am I contributing and how am I recognizing the needs of the patients? So we track all of our physicians in terms of our metrics. How many patients are we sending to outpatient therapies? These are my data, as well. I oversee the whole program, so this comes under my responsibility. Over the years, you can see where the pandemic hit in, as well. These are our numbers. Why can't we go further? Because we've reached maximum capacity for the space that we have. I talk to my chairman. We discuss it every now and then, and he says, okay, maybe we'll give you more space. I'll come back to that in a minute. But that's the trend that we love to see in terms of our volume. This is our specialized testing. So all of our stress testing, whether it's a regular stress test or a cardiopulmonary exercise test, comes under our department. So our numbers are going up. This makes us very relevant and very helpful to the health system. And these are overall the volume. Again, these metrics are key to justify why I go to work every day, why we have a department. And to then give backup to where are we going in the future? What are we going to do? So we have wait times and we have wait lists. For our cardiac program, we have about a month wait list. Not too bad. For our pulmonary program, we have a four-month wait list. I see my patients and I tell them, oh, yeah, come back in four months. It's just awful. Imagine not treating your patient for four months. Stay in pain for another four months, you'll be fine. And we've outgrown our stress testing capacity. We've essentially outgrown our space. Well, what have we done? We went from one site to five sites. Our program is growing across New York. I'm going to be real quick because I've got a minute left and we're 1025. We're going to have just a few minutes for questions. But I remember my chairman, before my current chairman, when I became a faculty, he said there were four A's. Well, I found 10 A's. So you can read through this list yourself. But these A's are all really important in terms of our culture, our philosophy, the work that we're doing and how we need to show and prove ourselves. Think of this, and I think this is a great teaching point for our residents and our medical students as well in terms of how to build a practice. Be a problem solver. Be their solution, as in the solution of our partners. Develop those partnerships. Have those communications with the clinical leads, the research leads, the administrative leads, and the education leads. That's how we make ourselves relevant. That's how we support and build our heart and lung rehabilitation programs for our transplant patients. We didn't always have a transplant program. It's been in the last seven or eight years. Before we did the first transplant at NYU, I sat down with the heart transplant leadership, who were already hired, and the pulmonary transplant leadership. We developed a playbook to make sure that we could take care of our patients well before they were coming in for their transplants, through the transplant process in the hospital, post-discharge, and then that lifelong perspective. It's really, really important. Essential talking points. You've seen this before. This is the PM&R bold statements. I'm not going to read them. You know what they are. We're essential throughout the continuum of care. We're indispensable. We see the whole patient. We see the whole picture. We have to back that up with our metrics. We have to positively impact the financials. We have to make sure that the patient-reported outcomes are there as well. That breeds brand loyalty. Patients are going to come back, and come back, and come back again. Our success story in Manhattan, because of our growth, the growth of the transplant program, our essential nature within the program, we are going to start very, very soon a renovation program that's going to double our CPEC capacity, and by a third, increase our outpatient capacity for our heart and lung transplant patients. So you can grow your program if you collect that data and those metrics. It makes it a no-brainer, although there's always going to be someone who's going to say, why? And shouldn't we put our money elsewhere? But be persistent. It's taken us actually three or four years to push this home, but we've got it. So hopefully I've covered my talking points. I want to thank you all. Again, I'm going to assume or hope that you are involved with heart and lung transplant rehabilitation. We are open to questions. We have about two minutes before we should vacate the room, but I know we have a little bit of wiggle room afterwards. But thank you all for being here. Questions? Akin, come up to the mic. Hi, Akin Bakley. I'm a Columbia, New York colleague, and this is excellent. I see a lot of these talking points, and I love the idea of using value-based medicine to speak with the people who know nothing about rehab or the value of rehab. My concern is I look around this room, and we're the ones who drank the Kool-Aid. We don't have, I don't know, if there are any residents here or medical students. And how do we get our residents and our medical students to have the passion for cardiac and pulmonary rehab and not just be thinking about sports and spying? So I know it's a loaded question, but I love it because I don't have the answer. So Akin, what I'm going to say to you is, yes, Akin and I just met. We interviewed him on the radio yesterday. Akin does vascular rehab, takes care of amputees, and we talked about supervised exercise therapy for peripheral arterial disease. How do you get patients on a cardiac rehab program for vascular disease to prevent that limb loss? How do you get patients on cardiac rehab to help them improve following strokes? How do you get patients on an aerobic exercise program like cardiac rehab to help them overcome their cancer or prevent cancer? You're right. We have a job to do. And if this group here is interested, let's put our heads together. Let's make it happen. You have to repackage and reframe and remarket cardiac rehab because our residents see it as inpatient hard work. And inpatient rehab is great. It's stimulating. It's wonderful. It's a little different as a resident than it is as an attending. We do have to address that. And that's come up at board meetings for the AAPMNR, and we are working on that, addressing it with residents and with program directors. But we have a lot of work to do. I'm going to stop because I know Karen wants to say something. Yeah, and I think I really work on individualized mentorship. You know, finding the one person that seems like they have the heart and really trying to cultivate that person throughout their training and involving them in initiatives. You know, making them feel like they have some stake in the game. And then the other thing I'm really trying to push is showing that this is lifestyle medicine. So we have our plenary this afternoon on lifestyle medicine, and this is what I do. This is absolutely what I do on patients that desperately need it and have challenges. And so that's the way that I'm trying to sell it. If you're interested in lifestyle medicine, boy, do I have the patient for you. We'll see. I don't know. I keep working at it. I know it'll work. We'll get one of them, right? We'll hook them in. It's hard though. I'm going to just eat humble pie on this. I've been trying for 30 years to get people to do cardiac and pulmonary rehab, and I have, I think, abjectly failed. There are people who are interested. No, no, no, no, no. No, I'm not talking about failing cardiac and pulmonary rehab. In getting mentees or trainees in mass to become interested. No, no. Oncology managed to do it. It's a complex population. A lot of our patients have similar mortality rates, if not worse, than cancer patients. We have a very powerful intervention that's type 1A evidence for both cardiac and pulmonary. There's more for cardiac than pulmonary. Pulmonary is 1B. But the thing is, we have better interventions, greater effect than any other intervention in rehabilitation. And I can't figure out how to light the fire. So I actually put out a plea, anybody who has an idea of how to make this sexy so that people want to join us, we are more than interested with open arms to welcome as many trainees as possible. And you'll never lack for patients. Cardiac and pulmonary disease are the number one and three killers in the United States. There's a lot of patients. So you can have impact, you can have a lot of effect. I haven't figured out how to make it light people's enthusiasm. So I'm willing to admit defeat on that one, but looking to see if people can actually help us figure out how to make this happen. I mean, you know, Dr. Whitesett and I both have fellowships, which are undersubscribed. So, you know, as an example. Any other questions? And if not, we'll wrap up. We're always available. You find us around and... Yes, go ahead. Come up to the microphone if you don't mind. So, we don't have telemetry on our inpatient rehab unit. We never wanted to go that far because of the significant complexity, although I'm open to considering it, but some of my colleagues are not. But we have telemetry for the patients when they're exercising in the gym, because then we're stimulating them and it's more likely to see some kind of arrhythmia. But no. Does anyone else have telemetry on their units, on their nursing units? They're chatting. I don't think so. Yeah. Yeah. Thank you all for attending. Thank you very much.

rehabilitation

transplant patients

heart and lung

prehabilitation

frailty assessments

team collaboration

early mobilization

outpatient care

psychological support

metrics-driven

medical trainees