Patients who have an intra-aortic balloon pump or a pulmonary artery catheter with vasoactive infusion while awaiting heart transplant have reduced mobility due to heart failure and activity restrictions. Stroke volume, respiratory capacity, and muscle strength decrease, and sleep disturbances occur. Patients require motivation to enhance ambulation.
To explore patients’ experiences with a fitness tracker to promote ambulation before heart transplant.
In 2017, a fitness tracker was issued to 43 patients before heart transplant who met the study criteria, which included orders to ambulate. Semistructured interviews were conducted after 2 weeks of fitness tracker use with 8 random participants, who were followed up to enhance the credibility of and validate the findings. Responses were interpreted by using descriptive phenomenology and purposive sampling. An expert in phenomenology examined the transcript interpretations and attested that the findings were supported by the data and were internally coherent. The Colaizzi method was used to analyze data.
A total of 361 significant statements were identified during the participants’ interviews and yielded 224 formulated meanings and 16 themes. Themes were categorized into 4 clusters: happy/delighted, motivator, beneficial, and future potential.
Participants were happy to get a fitness tracker and motivated to be active and increase activity/ambulation. Patients expressed benefits from walks: better sleep, more stamina, and feeling stronger. They believed that this intervention could have potential benefit for future patients.
The prevalence of heart failure (HF) has increased from 5.7 million to 6.5 million people aged 20 years and older in the United States (from 2009 to 2012), and it is projected to increase by another 46% between 2012 and 2030, involving more than 8 million people aged 18 years and older.1,2 Heart failure was a contributing cause in 1 of every 8 deaths in 2017.3
Patients with HF demonstrate symptoms that result from either a structural or functional cardiac disorder that damages the ability of the ventricles to fill with or eject blood. Diseases of the myocardium, endocardium, heart valves, and heart vessels, and metabolic disorders, can cause HF.3 Common signs and symptoms of advanced HF include dyspnea, fatigue, exercise intolerance, unintentional weight loss, refractory volume overload, hypotension, and signs of inadequate perfusion (diminished peripheral pulses or worsening renal function). A thorough patient history and a physical examination, blood tests, chest radiography, electrocardiography, transthoracic echocardiography, and exercise testing are evaluation procedures used to diagnose HF.4
Treatment of HF is aimed at 2 goals: reduced morbidity by reducing severity of symptoms, improving health-related quality of life and functional status, slowing disease progression, and decreasing the risk of hospitalization, and reduced mortality.5 Treatment of HF includes management of the cause of HF and its associated conditions, monitoring, preventive care, coordinated care, lifestyle modification, guideline-directed medical therapy and cardiac therapy, an implantable cardioverter-defibrillator, and mechanical circulatory support through ventricular assist devices and heart transplant.4–6 For many patients with advanced HF who become persistently symptomatic, notably those categorized in New York Heart Association functional class IV (HF refractory to optimal guideline-directed medical therapy and surgical therapy), heart transplant is the treatment of choice.7
The detrimental effects of prolonged low mobility result in severe, widespread physical deconditioning that affects multiple organs and systems.
At our medical center, patients with advanced HF who are awaiting a heart transplant are admitted to the cardiac intensive care unit (CICU) for pulmonary artery catheter monitoring, continuous intravenous inotropic infusions, and mechanical circulatory support.8 Patients stay in the CICU for a few days or a few months before transplant. During the waiting period, these patients are prone to suboptimal mobility.8
General weakness and being tethered to mechanical circulatory support machines (eg, an intra-aortic balloon pump [IABP] or a temporary ventricular assist device), electrocardiographic monitoring, a pulmonary artery catheter, and intravenous infusion pumps contribute to decreased patient mobility in the CICU.8 The detrimental effects of prolonged low mobility result in severe, widespread physical deconditioning that affects multiple organs and systems. In the critical care setting, patients can lose up to 30% of muscle mass within 10 days of admission and up to 15% of their muscle strength in 3 to 5 weeks.9,10
With prolonged decreased mobility—that is, within the first month of bed rest—stroke volume is reduced by 30%; this reduction is associated with an increase in resting heart rate.11 Signs of orthostatic intolerance can develop within 72 hours of inactivity.12–14 In patients with advanced HF, Q waves, ST and T wave abnormalities, tachycardia, new-onset atrial fibrillation, or ventricular tachycardia could cause symptoms of advanced HF to worsen.4 The decrease in respiratory capacity that results from the deconditioning of respiratory muscles, preventing full expansion of the chest wall during inspiration, can lead to the development of atelectasis and an increased likelihood of respiratory complications such as pneumonia.10,12 Additional complications associated with prolonged low mobility include a significant risk of developing decubitus ulcers, especially in poorly perfused older adults with HF, orthostatic hypotension, and thrombogenic events.13
Depression is common among patients with HF, and this condition could also affect their prognosis. In the study Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training (HF-ACTION), investigators administered the Beck Depression Inventory II to 2322 patients.15 They concluded that exercise modestly improved depression scores at 3 months.
Patients must be mobilized while waiting for a donor heart in the intensive care unit (ICU).8,16,17 Cardiologists at our institution have developed a novel approach to mobilize patients awaiting heart transplant: insertion of a percutaneous IABP in the left axillary-subclavian artery.8 This procedure is performed in the cardiac catheterization unit.
Patients with an axillary IABP are safely mobilized daily in our CICU.8 New nursing protocols and standard practice guidelines focusing on patient ambulation were created to align with the care required by patients with an axillary IABP awaiting heart transplant.18 One registered nurse helps stable patients with an axillary IABP to ambulate; the nurse spends about 5 minutes preparing the patient and disconnecting IABP cables, infusion pumps, and monitoring equipment.19 We explored the idea of obtaining fitness trackers for these patients to use while ambulating, and we decided to use funds from a Nursing Innovation Award to acquire 43 fitness trackers for this study.
Recruitment and Sample
We obtained approval from our center’s internal review board before the start of the study. From April through October 2017, we randomly selected patients to receive a Fitbit on the basis of various inclusion criteria: patients had to be awaiting heart transplant in the CICU; have orders to ambulate; speak English; have an active email address; and have access to a smartphone, tablet, or laptop computer. (Patients would use these devices to enroll in the established Fitbit group for patients awaiting heart transplant in our CICU.) Patients could be recruited as soon as they were placed on the heart transplant list with a 1A designation according to the 2017 heart transplant categories from the United Network for Organ Sharing.20 The 1A designation is the status code given to transplant candidates with the highest priority on the waiting list on the basis of medical urgency.20
Potential participants were approached in the afternoon, when patients rested and no activity was scheduled. The principal investigator (F.M.) or members of the study team met with potential participants and informed them about the study, reviewed the informed consent form, and explained the risks, benefits, and alternatives. A total of 43 patients voluntarily agreed to participate, and written informed consent was obtained from each participant.
In this study we used the Fitbit One fitness tracker (Fitbit, Inc.), which “tracks steps, floors climbed, distance walked, calories burned, motivational messages and active minutes.”20 It can be clipped to the patient’s gown or clothing and has a 14-day battery life. Patients’ statistics could be automatically downloaded and synchronized to a smartphone, a laptop computer (with an adapter provided with the Fitbit), and other smart devices.20
Once a patient agreed to participate, they were issued a new Fitbit One,21 and they were given a hard copy of the Fitbit One manual and the CICU Patient Guidelines for the Fitbit Project. The study team made patients aware that the Fitbit One tracks the distance and number of steps walked, calories burned, number of stairs/floors climbed, and time of day, and provides motivational messages. They taught patients the importance of keeping the device charged at all times. Patients were to wear the device during waking hours everyday. Patients also were to remind the nurse to record the distance/steps walked in their electronic medical record at the end of shift (6 pm). The patients were also told that the Fitbit is theirs to keep, but it would not be replaced if lost. The study team established a Fitbit group for the study participants and assisted patients in registering for the group. A member of the research team addressed all patients’ questions about the project and the fitness tracker, and study team members followed up with patients weekly to resolve any problems with or questions about the Fitbit and its use.
In one-on-one sessions with the nursing staff, the study team also provided instructions and a printed copy of the CICU Nurse Guidelines for the Fitbit Project. These guidelines included instructions on what and where to document in the electronic medical record, and to make sure that the patients put on the Fitbit as soon as they are out of bed in the morning. The instructions also reminded nurses that patient participation was voluntary. A printed copy of the nurse guidelines was posted by the patients’ room doors for easy reference.
In one-on-one sessions with the nursing staff, the study team also provided instructions and a printed copy of the CICU Nurse Guidelines for the Fitbit Project.
Our goal was to recruit 5 to 10 participants for interviews from among our group of 43 patients wearing a Fitbit; we selected 8 participants. We chose to interview only 8 participants because at that number we reached saturation in the exhaustive descriptions of patients’ experiences with using a Fitbit as an ambulation device. All 8 participants were interviewed after 2 to 3 weeks of wearing the Fitbit One tracker. In a qualitative study, saturation occurs when adding more participants does not add any additional perspective or description to the findings.21,22
Semistructured in-depth interviews are the most widely used interviewing method for qualitative research, and we used this format in this study. In qualitative research, questions are not “validated”; rather, the questions aim to elicit responses about the participants’ experiences and perceptions. Questions are often open-ended to elicit answers about the “what,” “how,” or “why” of a phenomenon (in this case, wearing a Fitbit), rather than “how many” or “how much,” which are answered through quantitative methods. This method requires a set of predetermined open-ended questions that gives the interviewer an opportunity to further explore particular responses through other emerging questions.23 Open-ended questions are a versatile tool that allow the interviewer to delve deeply into the phenomenon of interest, in this case the use of a Fitbit, while encouraging the interviewee to share rich descriptions of their lived experiences of the phenomenon.23,24
We created a semistructured interview guide for use during the individual interviews (Table 1). The interview guide had 6 questions, which we created to help us understand how the participants perceived their experience using the Fitbit during ambulation.
Data collectors were trained on how to interview the participants. Each interview was conducted in the patient’s room while they sat in a chair or laid in bed, and each lasted approximately 30 to 60 minutes. All participants tolerated the length of interview without difficulty. With permission from the participants, we audiotaped the interviews to allow us to create and confirm written transcripts.
The interviewers asked participants the questions from the semistructured interview guide (Table 1). They would be deliberately silent as needed to allow participants to reflect and elaborate on their viewpoints. This process allowed the interviewers to gain an in-depth understanding of the patients’ use of the Fitbit.
We used the Colaizzi method of data analysis, which consists of 9 steps: (1) describe the phenomenon of interest (in this case, patients’ experiences using a Fitbit during ambulation); (2) collect participants’ descriptions of the phenomenon; (3) read all participants’ descriptions of the phenomenon; (4) return to the original transcripts and extract significant statements; (5) spell out the meaning of each significant statement; (6) organize the aggregate formalized meanings into clusters of themes; (7) write an exhaustive description of the phenomenon; (8) return to the participants for validation of the description; and (9) if new data are revealed during the validation, incorporate them into the exhaustive description.25
To enhance the credibility of the findings, one research team member (F.M.) returned to the informants (via email and regular mail) to validate the findings. We used purposive sampling so we could maximize the range of specific information about the experience. For transferability, the principal investigator collected detailed data to report with sufficient detail and precision. To enhance the dependability of the study, a team member with a PhD (R.B.) who is experienced in phenomenological methodology examined the transcripts, interpretations, and recommendations, and attested that the findings were supported by the data and were internally coherent. To address confirmability, we preserved an audit trail (available upon request) to support any inquiries about the conclusions, interpretations, and recommendations and to trace them to their sources.25
We analyzed the data through 7 steps: interviews, significant statements, formulated meanings (across the group, based on the interview structure), themes, theme clusters, exhaustive description of the phenomenon, and a return to the participants to validate the description.
Each research team member read each transcript numerous times during simultaneous replay of the audio recording of the interview to capture the study participant’s feelings, tone of voice, and disposition as they expressed their feelings about their experiences with the fitness tracker as an ambulation-measuring device. The researchers extracted significant statements and phrases from each question and coded them. Significant statements or phrases have imparted meanings, which we called “formulated meanings.”
The demographics of the interviewed participants are shown in Table 2. Using the Colaizzi method, we identified 361 significant statements during the interviews, which yielded 224 formulated meanings. We grouped the formulated meanings on the basis of the interview questions, and 16 themes emerged. We then grouped these themes into 4 clusters to describe the phenomenon—the experiences of patients awaiting heart transplant who used the Fitbit One fitness tracker as an ambulation device.
The hospital ICU setting is usually not equated with patients being happy and excited. Patients undergo painful procedures, blood draws, and invasive and noninvasive tests almost every day. Thus, the first cluster of themes identified from the patient interviews—happy, excited— was somewhat surprising (Table 3). The participants indicated that they were happy to receive the fitness tracker because they felt that it would be beneficial to them and other patients with the same condition (HF), as it would challenge and motivate them to walk. One participant responded that the fitness tracker did not make him feel anything; he wanted it only to satisfy his curiosity.
The second theme cluster was that the fitness tracker motivated and challenged the patients to walk more. These patients are debilitated and weak from HF by the time they are placed in category 1A on the heart transplant list. They require increased motivation to enhance ambulation. When these patients were given a fitness tracker, they became more motivated to walk and mobilize (Table 4). The Fitbit One has an organic light-emitting diode display on which the patients can see the number of steps that they walked that day. This display, which the patients can easily access, is one reason they cited for being more motivated. The patients also cited a desirable secondary benefit from walking: better sleep at night.
The third theme cluster was that the fitness tracker was beneficial as an ambulation-measuring device (Table 5). The patients expressed a sense of achievement while using the fitness tracker in this capacity. They further expressed that the fitness tracker motivated them to increase ambulation each day and set new personal goals, which actively engaged the patients in goal setting as it pertained to their plan of care. Reported benefits included better sleep, increased stamina, and feeling stronger. One patient stated that improved strength could benefit them during the postoperative recovery process. This statement reflects the main purpose of increasing patients’ ambulation before heart transplant.
The fourth theme cluster was that the fitness tracker had the potential to benefit future patients requiring a heart transplant (Table 6). Our participants appreciated the use of this common technology as a complement to their physical activity and as a device for socializing with other patients and family members through the CICU pre– heart transplant Fitbit group.
Studies have shown that long hospital stays and bedrest have deleterious effects on multiple organs. Patients awaiting heart transplant in the CICU are especially vulnerable to these effects because of their low cardiac output, which results in shortness of breath and poor multiorgan perfusion. In addition, patients are tethered to monitoring equipment, infusion pumps, and mechanical assist devices that support their heart but limit their mobility while they wait for a heart transplant. Early and consistent ambulation for these patients thus becomes a problem. Motivating these patients to walk despite these problems is important.26,27
Multiple quantitative studies have shown that using step counters in cardiac rehabilitation and telerehabilitation can assist in patients’ recovery.28–30 We found no qualitative studies focusing on how patients feel about using a in an ICU setting, so in this study we focused on examining the experiences of these participants. The fitness tracker enabled the patients to access real-time data as they walked, after walking, or at the end of the day, when they could see their total number of steps and distance walked. They could then determine whether, depending on their physical condition, they could increase their number of steps the next day. The fitness tracker complements the physical therapy plan of care presented to the patients at the start of their physical therapy treatment.
Some of the participants believed the fitness tracker, as an ambulation device, could help future patients to be active while waiting for a heart transplant.
Limitations of the study include that it was a single-institution study with predominantly male interviewees (7 of 8 participants). Of the 8 participants interviewed, only 5 responded to verify the research findings. One respondent who verified the findings commented that the Fitbit fitness tracker is not as accurate as another activity tracking device he began using after his discharge home, suggesting that different brands of activity trackers have varying degrees of accuracy. Another limitation is that the participants might subconsciously be trying to please us because we gave them a free Fitbit One. Despite these limitations, with the information gathered from this qualitative study, we can identify variables that could lead to the development of a quantitative study, such as measuring postoperative mean extubation times, mean time of first ICU ambulation after transplant, total postoperative ICU length of stay, and total postoperative hospital length of stay.
This study exemplifies the application of inexpensive, modern, commercially available technology as a complement to traditional care for patients awaiting heart transplant in the ICU. This study could lay a foundation for future studies of the benefit of a fitness tracker in encouraging ambulation not only for patients with HF but also for chronically ill patients who require prolonged hospital stays.
Overall, the participants had a favorable experience with the fitness tracker as an ambulation device. Those we interviewed claimed that using the fitness tracker provided benefit in their ambulation activity. They were happy to get a fitness tracker, and it motivated them to walk more and stay active. Because the participants were active during the day, they slept better at night, and their stamina increased. They felt stronger, and they believed this increased strength would be helpful during their postoperative recovery. Some of the participants believed the fitness tracker, as an ambulation device, could help future patients to be active while waiting for a heart transplant.
The authors thank the Brown Foundation for a Nursing Innovation Award, won by Frederick Macapagal, which funded the Fitbits used in this study.
To purchase electronic or print reprints, contact the American Association of Critical-Care Nurses, 27071 Aliso Creek Rd, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; email, firstname.lastname@example.org.
To learn more about heart transplant, read “Electrocardiographic Correlates of Acute Allograft Rejection Among Heart Transplant Recipients” by Hickey et al in the American Journal of Critical Care, 2018;27(2):145-150. Available at www.ajcconline.org.