Journal Response

R E S E A R C H I N B R I E F

The effect of ambulation after cardiac catheterization on patient

outcomes

Sek Ying Chair MBA, PhD, RN

Assistant Professor, The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong, China

David R Thompson PhD, MBA, RN, FRCN, FESC

Director and Professor of Clinical Nursing, The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong

Kong, China

Shu Kin Li MBBS, FRCP

Chief of Service, Department of Medicine, Pamela Youde Nethersole Eastern Hospital, Hong Kong, China

Submitted for publication: 24 August 2005

Accepted for publication: 26 January 2006

Introduction

Cardiac catheterization remains the most definitive procedure

for diagnosis and evaluation of coronary artery disease

(Woods et al. 2005). Currently, cardiac catheterization has

become a routine diagnostic procedure performed in many

hospitals in Hong Kong. Although it can be performed

through brachial, radial, or femoral arteries (Woods et al.

2005), the transfemoral puncture is the most common

approach (Noto et al. 1991, Chair et al. 2003). However,

because vascular complications occur in 0Æ43–5Æ8% of

transfemoral cardiac catheterization patients (Noto et al.

1991, Lehmann et al. 1997, Chair et al. 2003), strict bed rest

and immobilization of the catheterized leg have been consid-

ered essential to reduce the risk of their development

(Grossman 1980, Woods et al. 2005). The recommended

bed rest duration after transfemoral cardiac catheterization

varies from two to 24 hours (Baum & Gantt 1996, Chair

et al. 2003). Many patients find it difficult to use the bedpan

or urinal in the recumbent position during bed rest, more-

over, studies reported that back pain severity increased with

longer duration of bed rest after cardiac catheterization

(Barkman & Lunse 1994, Baum & Gantt 1996, Chair et al.

2003). Therefore, to obtain optimal patient outcomes, the

length of bed rest duration after cardiac catheterization

should be minimized.

Aims

The aims of this study were to compare patient outcomes of

vascular complications, back pain, and urinary discomfort

between patients ambulated at four and 12–24 hours (usual

care) post-transfemoral cardiac catheterization.

Methods

Patients admitted for elective cardiac catheterization at a

general hospital in Hong Kong Island were recruited to the

study. Inclusion criteria were that patients should be ethnic

Chinese, aged over 18 years, had no bleeding disorders, were

not receiving anti-coagulant therapy within the previous

24 hours before the procedure, had no back pain, blood

pressure <180/110 mmHg before the procedure and no

complications developed during cardiac catheterization.

Patients were randomly assigned to either a control or

experimental group according to a computer-generated

random table of number. Patients in the experimental group

were ambulated after four hours bed rest postcardiac

catheterization, whereas patients in the control group were

ambulated the morning after the procedure, 12–24 hours

Correspondence: Sek Ying Chair, The Nethersole School of Nursing,

The Chinese University of Hong Kong, Shatin, New Territories,

Hong Kong, China. Tel: (852) 2609 6225, E-mail: sychair@cuhk.

edu.hk

� 2007 Blackwell Publishing Ltd 212 doi:10.1111/j.1365-2702.2006.01599.x

after bed rest depending on the time the patient had the

procedure completed during the day (usual care).

The puncture site was assessed for vascular complications

hourly for the first six hours then the next morning at

08:00 hours using the guidelines (Christenson et al. 1976).

Significant bleeding was defined as blood loss estimated at

>100 ml, haematoma >5 cm in width or bleeding that led to

further attempts to reestablish haemostasis by manual pres-

sure, sandbag, or reinforcement of pressure dressing. For all

patients, back pain was assessed at four hours, eight hours and

the next morning at 08:00 hours after cardiac catheterization

by using a visual analogue scale consisting of a 100-mm long

line with the left anchor representing ‘no pain’, and the right

anchor representing ‘the worst possible pain’. Urinary discom-

fort was assessed at six hours after the procedure by use of a

five-point Likert scale self-developed measurement consisting

of four questions, a higher value referring to more urinary

discomfort. The test–retest reliability of the urinary discomfort

measurement on 18 subjects was significantly correlated

(r ¼ 0Æ95, P < 0Æ001), and the Cronbach’s alpha was 0Æ876.

Findings

A total of 86 (male, n ¼ 41; female, n ¼ 45) subjects completed the study, 43 in each group with a mean age of

63 years (SD ¼ 9Æ6, range 34–75). Fifty-six (65%) subjects had either received no formal education or were educated at

elementary level, and eight (9Æ3%) had received a college

education. Most (65Æ1%) subjects had a monthly family

income <HK$8000 (approximately US$1000). Seventy-one

patients (82Æ6%) were either retired or housewives. Table 1

shows that the two groups were not significantly different in

age, gender, education level, and monthly household income.

Occupation status was significantly different between the two

groups (chi-square, P ¼ 0Æ009) with more retired subjects in the control groups but more housewives in the experimental

group.

There was no difference between the two groups on vascular

complications. One subject in the control and none in the

experimental group developed bleeding at the puncture site

that required manual pressure to re-establish haemostasis

(Fisher’s exact test, P ¼ 1). Repeated measures analysis of variance was used to evaluate the back pain experienced across

time and between groups. There was a significant difference

between the two groups at the three time intervals on back

pain intensity (F2,83 ¼ 9Æ80, P < 0Æ001) with the control group reporting more pain at each time interval. Moreover,

the two groups also differed significantly on urinary discom-

fort (t65Æ6 ¼ 3Æ24, P ¼ 0Æ006) with the control group experi- encing higher levels of urinary discomfort (Table 1).

Table 1 Demographic and outcomes comparisons between groups

Control (n ¼ 43) Experimental (n ¼ 43) P-value Statistical test used

Age [years: mean (SD)] 63Æ2 (±9Æ7) 62Æ7 (±9Æ7) 0Æ816 t-Test Gender, n (%)

Male 19 (44Æ2) 22 (51Æ2) 0Æ517 Chi-square Female 24 (55Æ8) 21 (48Æ8)

Educational level, n (%)

No formal education 11 (25Æ6) 12 (17Æ9) 0Æ729 Mann–Whitney U-test Primary school 16 (37Æ2) 17 (39Æ6) Secondary school 13 (30Æ2) 9 (20Æ9) University 3 (7) 5 (11Æ6)

Monthly household income, n (%)

£HK$8000 22 (51Æ2) 34 (79) 0Æ052 Mann–Whitney U-test HK$8001–$18 000 14 (32Æ6) 6 (14) >HK$18 001 7 (16Æ2) 3 (7)

Occupation, n (%)

Retired 30 (69Æ8) 21 (48Æ8) 0Æ009 Chi-square Housewife 4 (9Æ3) 16 (37Æ2) Presently working 9 (20Æ9) 6 (14)

Vascular complications, n (%) 1 (2Æ3) 0 (0) 1Æ00 Fisher’s exact test Back pain

Four hours 1Æ55 0Æ97 <0Æ001 Repeated measure of ANOVAANOVA Eight hours 4Æ41 1Æ34 The next morning 4Æ01 1Æ77

Urinary discomfort 2Æ57 1Æ09 0Æ006 t-Test

Research in brief

� 2007 Blackwell Publishing Ltd, Journal of Clinical Nursing, 16, 212–214 213

Discussion

Prolonged bed rest in the supine position is difficult for many

patients who have undergone cardiac catheterization. Some

patients complain of back pain and have the desire to move

from side to side. Others complain of difficulty to urinate in a

supine position. In this study, patients allowed to ambulate at

four hours postcardiac catheterization experienced signifi-

cantly less back pain and less urinary discomfort, but did

not experience any increase in vascular complications at

puncture site.

The average age, high unemployment rate, low education

standard and low-income level of patients in this study was

reflective of the study site which is less affluent than the

general Hong Kong population

Implications for practice

The results suggests that early ambulation may play a

substantial role in reducing back pain and urinary discomfort

in post-transfemoral cardiac catheterization. Allowing pa-

tients to get out of bed after four hours of bed rest following

cardiac catheterization could be introduced into routine

practice in Hong Kong, as it was found to be safe and might

aid in promoting patient comfort without increasing the

incidence of vascular complications. In addition, the shorter

bed rest duration may reduce the nursing time needed for

administering analgesics or back rubs to relieve back pain.

Early ambulation after cardiac catheterization may also

reduce the nursing time needed for assisting patients to use

urinal and bedpan during bed rest period after the procedure.

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