Empowering Patients Before Heart Transplant With a Walking Competition

Heart transplant is the definitive treatment for advanced heart failure in patients for whom medical therapy was unsuccessful. In 2022, a total of 3668 adults received heart transplants in the United States, and the wait times for these patients ranged from less than 90 days to more than 2 years.1 Patients with prolonged wait times may experience hemodynamic and physical deterioration, emotional distress, and depression.2 Depression is common among patients with heart failure, and the inability of some patients to be with family and friends while hospitalized is an added stressor. Many patients travel far to be treated at transplant centers. Because of the caregiver requirements in the postoperative period, some caregivers must continue to work until the time of transplant, leaving patients without loved ones nearby. Patients who build meaningful relationships with nursing staff and other patients can boost their mental well-being and psychological resilience, which helps to combat depression.3In the past, patients awaiting heart transplant were limited to medical therapy or durable left ventricular assist devices (LVADs) as a bridge to transplant. Although placement of an LVAD allowed patients to eventually return home until the time of transplant, the placement procedure was a major surgery with associated risks. Recent advancements in technology, such as temporary mechanical cardiac support devices, have allowed patients to improve their physical abilities while waiting for a heart transplant. Although patients with these devices are confined to the intensive care unit (ICU), they can ambulate as tolerated with the assistance of nursing staff.4Since 2018, our facility has seen an increase in the number of patients awaiting heart transplant with axillary temporary mechanical cardiac support devices in place (intra-aortic balloon pump; Impella, Johnson & Johnson MedTech). The additional cardiac support provided by the pumps enables patients to feel better despite the deconditioning they experience as a result of their chronic illness. We have seen these patients slowly increase their strength before transplant, with some patients walking more than 5 miles daily while in the ICU.Although the initiative we describe here was an adjustment for patients and nurses alike, the nursing staff embraced this opportunity to encourage this patient population. After observing patients waiting for heart transplants walking in circles around the unit all day long, we conceived the idea of a simple race board to encourage and entertain the patients while they waited patiently for their new organs.The first group of “racers” were encouraged by our initiative. The patients chatted at the race board, sometimes walked together, and observed what others were doing. They slowly formed friendships. Our creative staff members took patients outside for sunshine privileges and organized game days inside. One nurse found images representing the patients’ race names and posted the pictures on the race board and the patients’ heart pumps. Patients chose names of sports teams, favorite movies, or objects that reminded them of their family or their journey. The signs allowed the patients to share something about themselves other than being a patient in the ICU. The race, which started as a fun diversion for the patients, is now standard practice on our unit 3 years later.This nurse-led exercise initiative required little effort to begin, but buy-in from staff was essential to its success. We spoke to each patient about the “competition,” asked them to think up a race name, and secured a poster board, and the race was on! Patients added a hash mark on the race board for each lap they completed—with their pump and a nurse—around the unit. Even without prizes, all the patients strived to better themselves every day.We took care to avoid high-traffic areas during emergencies or other sensitive times. Given their enthusiasm for competition, some patients had to be told to slow down. We planned game days in accordance with appropriate unit staffing, room space, and physician approval. We communicated with the campus response team to provide an additional level of staff support when patients were outside the ICU.Nursing staff enjoyed watching the patients increase their lap counts every day. In addition to the patients’ increased walking distances, we also noted the connections patients made with each other and with staff members. The signs on the patients’ heart pumps and the race board served as an icebreaker when patients encountered people in the hallways. The friendships enabled by the race have continued beyond transplant and discharge. The patients enjoyed having this connection to others needing heart transplants, as only they can truly empathize with each other’s journeys. Many of the patients recovered at a local facility for transplant patients, where they continued to play the games they learned while in the hospital and attended rehabilitation together. After their transplants, some patients participated as a team in the American Heart Association Heart Walk.Inspired by the positive energy of the race, and encouraged by our clinical nurse specialist and the attention from physicians in the unit, we embarked on a nursing research study. With expert guidance from our nurse scientist, we designed a study to document collective changes in patients’ physical functioning, quality of life, sleep disturbance, and sleep-related impairment from the time of device implant until the time of heart transplant. This study is a rare opportunity to showcase the impact of a nursing initiative on these debilitated ICU patients, and we look forward to sharing our results.The author thanks all the staff members on 4 South for their enthusiasm, engagement, and support of our patients on their journeys and for their support in this initiative and research project.