Nationwide Survey of Japanese Cardiac Rehabilitation Training Facilities During the Coronavirus Disease 2019 Outbreak.

Background: Since the reporting of a cluster outbreak of coronavirus disease 2019 (COVID-19) in sports gyms, the Japanese Association of Cardiac Rehabilitation (CR) shared a common understanding of the importance of preventing patients and healthcare providers from contracting COVID-19. This questionnaire survey aimed to clarify the status of CR in Japan during the COVID-19 outbreak. Methods and 
Results: An online questionnaire survey was conducted in 37 Japanese CR training facilities after the national declaration of a state of emergency in 7 prefectures. Among these facilities, 70% suspended group ambulatory CR and 43% suspended cardiopulmonary exercise testing (CPX). In contrast, all facilities maintained individual inpatient CR. Of the 37 facilities, 95% required CR staff to wear a surgical mask during CR. In contrast, 50% of facilities did not require patients to wear a surgical mask during CR. Cardiac telerehabilitation was only conducted by a limited number of facilities (8%), because this method was still under development. In our survey, 30% of the facilities not providing cardiac telerehabilitation had specific plans for its future use. Conclusions: Our data demonstrate that ambulatory CR and CPX were suspended to avoid the spread of COVID-19. In the future, we need to consider CR resumption and develop new technologies for cardiovascular patients, including cardiac telerehabilitation.

On April 1, 2020, the Japan Cardio-Vascular Alliance was established, and the Japanese Association of Cardiac Rehabilitation (JACR) joined the alliance. The initial focus of coronavirus disease 2019 (COVID-19) was primarily on infectious diseases, especially pneumonia, but it gradually became evident that vascular endothelial injury and thrombosis were significantly related to cardiovascular diseases. A nationwide survey in Japan by the Japanese Circulation Society reported both low clinical case experiences with COVID-19 and restrictions to cardiovascular procedures during the first COVID-19 wave in Japan. COVID-19 has become the global threat, and the number of infected patients in Japan has increased rapidly, particularly in the main urban areas. Although the Japan Cardio-Vascular Alliance was not initially established for COVID-19, it turned out to be a good timing as we were faced with an emergency situation that no one had ever experienced before. The Japanese Society of Cardiology organized a COVID-19 Task Force Mission Team to disseminate prompt information and to suggest collaborations with other departments and hospitals on April 10, 2020., The COVID-19 pandemic induced healthcare providers to change their respiratory management strategy for patients with acute heart failure (HF), especially in alert areas. Since the widespread reported of a cluster outbreak of COVID-19 in sports gyms, the JACR shared a common understanding of the importance of preventing patients and healthcare providers from contracting COVID-19.

On April 7, 2020, the Japanese government first declared a national state of emergency over the novel coronavirus outbreak in 7 prefectures (Saitama, Chiba, Tokyo, Kanagawa, Osaka, Hyogo, and Fukuoka), including main urban areas, and announced the high risk of the occurrence of clusters when the 3Cs (closed spaces with poor ventilation; crowded places with many people nearby; close-contact settings, such as close-range conversation) overlap. It is quite difficult to avoid the 3Cs in cardiac rehabilitation (CR). Therefore, it is crucial that sufficient measures are enforced to prevent infection among healthcare providers and patients undergoing CR, as well as to prevent the spread of nosocomial infection, and to continuously provide appropriate and safe CR and cardiopulmonary exercise testing (CPX).

Studies have reported the status of CR in Japan before the COVID-19 outbreak.– Recently, one facility reported that the participation rate of HF patients in a remote CR program increased during the COVID-19 pandemic in Japan. However, to the best of our knowledge, we have no data from detailed studies concerning the CR situation in Japan during the COVID-19 outbreak; thus, investigating the current CR situation is an urgent issue.

In this study, we used a questionnaire to determine what measures were taken in CR training facilities against the COVID-19 outbreak after the Japanese government’s declaration of a state of emergency.

Methods

An online questionnaire was created Google Form and emailed to 40 Japanese CR training facilities on April 13, 2020, after the declaration of a state of emergency in 7 major prefectures but before the nationwide declaration. The data obtained were compiled by the Public Relations Committee of the JACR. The questionnaire included basic information for each of the facilities, exercise therapy implementation, exercise testing, cardiac telerehabilitation, patient guidance, and other aspects affecting CR implementation and education. Based on the results of the questionnaire, we assessed differences among facilities (between those accepting patients with COVID-19 and those not) and regions (between those under a state of emergency and those not).

Ethical Considerations

The study protocol was approved by the St. Marianna University School of Medicine Institutional Committee on Human Resource, Kawasaki, Japan (No. 4863). The study was performed in accordance with the Declaration of Helsinki.

Statistical Analysis

Categorical data are expressed as numbers and percentages. Intergroup differences were evaluated using Fisher’s exact test for categorical variables. Statistical analyses were conducted using JMP® Pro 14.2.0.

Results

Of the 40 Japanese CR training facilities that received the questionnaire, 37 (92.5%) completed the survey: 13 facilities in the Kanto region, 7 each in the Kinki and Kyushu regions, 3 in the Tohoku region, 2 each in the Hokkaido and Chugoku regions, and 1 each in the Tokai, Hokuriku and Shikoku regions (). Of the 37 facilities (22 university hospitals, 15 general hospitals), 28 (76%) accepted patients with COVID-19 and 10 (37%) encountered COVID-19 cases.

Figure.

Distribution of cardiac rehabilitation (CR) facilities during the COVID-19 outbreak in Japan. The areas delineated by the red lines on the map show regions where the Japanese government first declared a national state of emergency because of the novel coronavirus outbreak (7 prefectures: Saitama, Chiba, Tokyo, Kanagawa, Osaka, Hyogo, and Fukuoka). The source of the figure is the Geographical Survey Institute (https://maps.gsi.go.jp/development/ichiran.html).

Of the 37 facilities, 70% suspended group ambulatory CR (). There were no significant differences in the suspension of group ambulatory CR between facilities that did and did not accept patients with COVID-19 (32% vs. 22%, respectively; P=0.57) or between regions under a state of emergency and those not (21% vs. 39%, respectively; P=0.24). The suspension of inpatient group CR was decided by individual facilities; 51% of facilities continued group CR and the remaining 49% suspended group CR. There were no significant differences in the suspension of inpatient group CR between facilities that did and did not accept patients with COVID-19 (57% and 33%, respectively; P=0.21) or between regions under a state of emergency and those not (53% and 50%, respectively; P=0.87). In contrast, all facilities maintained individual inpatient CR.

Table 1.

Status of Cardiac Rehabilitation Facilities During the COVID-19 Outbreak

Survey items	All (n=37)	Facility status			Facility regions
		Accepting COVID-19 patients (n=28)	Not accepting COVID-19 patients (n=9)	P value	In a state of emergencyA (n=19)	Not in a state of emergency (n=18)	P value
Continuing group ambulatory CR: Yes	11 (30)	9 (32)	2 (22)	0.57	4 (21)	7 (39)	0.24
Continuing group inpatient CR: Yes	19 (51)	16 (57)	3 (33)	0.21	10 (53)	9 (50)	0.87
Continuing individual inpatient CR: Yes	37 (100)	28 (100)	9 (100)	–	19 (100)	18 (100)	–
Cancellations of ambulatory CR from patients: Yes	29 (78)	22 (79)	7 (78)	0.96	16 (84)	13 (72)	0.38
Requirement for CR staff to wear surgical masks during CR: Yes	35 (95)	27 (96)	8 (89)	0.38	18 (95)	17 (94)	0.97
Requirement for patients to wear surgical masks during CR: Yes	17 (46)	12 (43)	5 (56)	0.51	8 (42)	9 (50)	0.63
Disinfection before and after CR: Yes	33 (89)	25 (89)	8 (89)	0.97	16 (84)	17 (94)	0.32
Modified regular CR: Yes	33 (89)	25 (89)	8 (89)	0.97	17 (89)	16 (89)	0.95
Continuing treadmill test: Yes	24 (65)	18 (64)	6 (67)	0.90	10 (53)	14 (78)	0.11
Continuing CPX: Yes	21 (57)	15 (54)	6 (67)	0.49	8 (42)	13 (72)	0.06
Modified regular CPX: Yes	21 (57)	17 (61)	4 (44)	0.39	11 (58)	10 (56)	0.89
Conducting remote CR programs: Yes	3 (8)	1 (4)	2 (22)	0.07	3 (16)	0 (0)	0.08
Continuing patient education for inpatients: Yes	6 (16)	6 (21)	0 (0)	0.13	4 (21)	2 (11)	0.41
Changes in instructional content: Yes	17 (46)	15 (54)	2 (22)	0.10	10 (53)	7 (39)	0.40

Unless indicated otherwise, data are presented as n (%). ASaitama, Chiba, Tokyo, Kanagawa, Osaka, Hyogo, and Fukuoka. CPX, cardiopulmonary exercise testing; CR, cardiac rehabilitation.

Of the 37 facilities, 95% required CR staff to wear a surgical mask during CR. In contrast, 50% of facilities did not require patients to wear a surgical mask during CR. No facilities status and regional differences were observed in 90% of the facilities disinfected the CR room before and after each CR session (89% and 89%, P=0.97; 84% and 94%, P=0.32, respectively).

Of the 37 facilities, 65% continued with treadmill testing, whereas approximately half the facilities in areas under a state of emergency decided to suspend it. CPX was suspended in 43% of facilities, including 58% of facilities in areas under a state of emergency (vs. 28% in areas not under a state of emergency), and this decision greatly varied according to region.

Cardiac telerehabilitation was only conducted by a limited number of facilities (8%), because this method was still under development. In our survey, 30% of the facilities not providing cardiac telerehabilitation had specific plans for its future use.

From the survey results, 84% of facilities suspended group inpatient education. Because alternative items were not included in the questionnaire, it was assumed that group inpatient education shifted to individualized instruction. The details remain unclear. With the spread of COVID-19, approximately half the surveyed CR facilities have made additional changes to their instructions and procedures.

Discussion

Many departments restricted their cardiological procedures, and this rate changed according to the pandemic situation. The exacerbation of cardiovascular disease resulting from pandemic restrictions should not be ignored. This survey included 19 facilities (51%) located in the 7 prefectures where the state of emergency was first declared on April 7, 2020. The declaration of a state of emergency was expanded nationwide on April 16, 2020. This survey had been conducted before the CR guidance was published by the Japanese Association of Cardiac Rehabilitation on April 20, 2020, and each facility’s decision appeared to be based on whether the facilities was in an area under the state of emergency, and not whether the facility was accepting patients with COVID-19. Of note, 80% of the facilities experienced ambulatory CR cancellations from patients. This suggests an improved awareness of patients, which was one of the main objectives in ambulatory CR.,

Notably, 89% of the facilities took various measures to avoid the 3Cs in both group and individual CR at the discretion of each facility (). These detailed measures should be promptly shared by all CR facilities.

Table 2.

How to Avoid the 3Cs (Closed Spaces, Crowded Places, and Close-Contact Settings) in CR

Closed spaces with poor ventilation

• Ensure regular ventilation of the rehabilitation room

• Consider the well-organized placement of patients

Crowded places with many people nearby

• Change group exercise therapy sessions to individualized instruction (1 : 1 sessions)

• Reduce the number of patients in each session as much as possible

• Provide CR to inpatients in hospital wards and not in rehabilitation rooms where other rehabilitation patients gather

Close-contact setting, such as close-range conversation

• When using cycle ergometers and treadmills, keep a minimum distance of 2 m between patients

• Ensure all patients and CR staff wear surgical masks

• Avoid cough-inducing exercises

CR, cardiac rehabilitation.

When we perform CPX, we are at risk of infection exposure from the respiratory droplets of patients coughing, which can cause viral aerosolization. Approximately 60% of facilities decided to conduct inspections and established infection control measures. Decisions regarding stress exercise testing, including CPX, should be based on individualized risk assessment and a patient’s clinical status. Shared decision making between the patients and the CR team is an important component.

Cardiac telerehabilitation was only conducted by a limited number of facilities at the time of the survey because this method was still under development. In our survey, 30% of facilities not providing cardiac telerehabilitation had specific future plans, suggesting the possibility of further development of cardiac telerehabilitation during the COVID-19 outbreak.–

For safe CR during the COVID-19 pandemic:

• to avoid crowds, group rehabilitation and instruction should be suspended

• to avoid excessive (patient) resting, CR staff should allow patients to walk about in a restricted area under certain conditions and instruct them as to how to perform aerobic exercises and muscle strength training at home

• to avoid further spread of COVID-19, the use of face masks and hand washing are compulsory.

The status of CR was assessed based on the results of the questionnaire. The data obtained demonstrated that ambulatory CR and CPX were suspended to prevent the spread of COVID-19. Thus, it is essential to identify measures that should be taken at appropriate times. At present, there is a need to establish new CR strategies for continuous prevention in cardiovascular patients, such as the development of new technologies providing appropriate and safe CR even during a pandemic., We believe that we will be able to provide appropriate and safe CR to medical professionals and patients even during the COVID-19 outbreak by using suitable guidelines and cardiac telerehabilitation.

Conclusions

Our data demonstrated that ambulatory CR and CPX were suspended to avoid the spread of COVID-19. In the future, we need to consider CR resumption and develop new technologies for cardiovascular patients, including cardiac telerehabilitation.

Sources of Funding

This study did not receive any specific funding.

Disclosures

K.N. is a member of Circulation Reports’ Editorial Team. The remaining authors report no potential conflicts of interest.

IRB Information

The study protocol was approved by the St. Marianna University School of Medicine Institutional Committee on Human Resource, Kawasaki, Japan (No. 4863).

Supplementary Appendix