Promoting early ambulation in patients after coronary angiographic procedures
A patient recovering from a coronary angiographic procedure is typically confined to prolonged bedrest. Coronary angiographic procedures, encompassing angiography and angioplasty, represent the gold standard diagnosis and treatment for coronary artery disease. However, prolonged bedrest following coronary angiographic procedures is often linked to patients feeling frustration, discomfort, or anxiety due to immobility and the use of bedpans or urinals. Recognising these issues, nurses at the National University Hospital (NUH) in Singapore are championing evidence-based interventions, such as early ambulation to enhance both patient experience and recovery.
Background
The National University Hospital is Singapore’s leading university hospital, inculcating a strong culture of evidence-based practice among nurses in driving clinical innovation and influencing positive clinical outcomes. One of the ways the hospital does this is by enrolling nurses in training programs. As a JBI Centre in Singapore, NUH offers the JBI Evidence Implementation Training Program. This program guided senior staff nurse, Ellene Lim, to implement strategies to promote early ambulation in patients after coronary angiographic procedures at the National University Heart Centre.
Ellene’s motivation for implementation initiatives stems from her frontline experience in the Coronary Monitoring Unit, where she observed how traditional, experience-based practices could negatively affect both patient recovery and nursing workload.
“When I saw how small changes rooted in evidence could dramatically improve our patients’ comfort and recovery, I knew this was the kind of change I wanted to lead. Being part of a program that supports nurses to turn insights into action has not only sharpened my clinical lens but has also shown me how empowered nurses can drive meaningful change.”
Challenging the bedrest norm
In the Coronary Monitoring Unit, silence often speaks volumes. The quiet discomfort of a patient immobilised in bed after a coronary angiographic procedure, the sigh of a nurse adjusting a bedpan for the third time in an hour, the subtle wince from back pain that words can’t quite capture—all of these moments tell a story that many of us in nursing have grown used to.
For years, the post-procedure routine was simple but strict: after a coronary angiographic procedure, patients remained on complete-rest-in-bed (CRIB). CRIB meant patients were to lie flat with no hip flexion for at least 6 hours—sometimes up to a full day. The rationale was clear: minimise vascular complications. But the cost of this caution was becoming hard to ignore. Patients reported aching backs, urinary retention, and the emotional frustration of relying on bedpans. Some grew anxious or even angry, with feelings often directed at the nurses caring for them: “I had terrible back pain and was scared to move,” one patient shared. “But I didn’t want to use the bedpan either.” At the same time, nurses were navigating their own discomfort: the inner tension between what they had always done and what might now be possible.
It was during one of the team’s routine reflections that the discrepancy became impossible to ignore. CRIB durations varied drastically between 6 to 24 hours, without any clear consensus. It wasn’t hard to trace this inconsistency back to experience-based decisions rather than a shared, evidence-based protocol. The question surfaced quietly but persistently: What if we could do better—for our patients and for ourselves?
Turning evidence into action: Implementing early ambulation
That question sparked the beginning of a nurse-led initiative to challenge the status quo. We began by forming a small, multidisciplinary team of nurses, doctors and physiotherapists, grounded in a shared belief that recovery could look different. Our team explored the idea of early ambulation after percutaneous coronary intervention—a concept gaining traction in the recent literature. Our first task was to synthesise the existing evidence and benchmark it against international best practices, while also recognising the unique culture and context of our unit.
The project was guided by JBI’s Evidence Implementation Framework. Our team conducted a targeted review of best practices, engaged key stakeholders as change agents, assessed local context readiness, and integrated structured implementation tools, including JBI’s Practical Application of Clinical Evidence System software (JBI PACES) and the Getting Research into Practice (GRiP) method.
The intervention focused on enabling patient ambulation 4 hours after coronary angiographic procedures, and evaluating its effects on outcomes such as back pain, urinary difficulty, and vascular complications. The process involved three key phases: patient education, vascular access site assessment during pressure bandage removal, and nurse-supervised ambulation between 4 to 5 hours post-procedure.
Very soon, the team realised that mere knowledge wasn’t enough. The bigger challenge was navigating longstanding mindsets. Most nurses remained hesitant—particularly about ambulating patients with femoral access—citing past experiences with bleeding or haematoma formation. Rather than dismissing these concerns, we created space for focused group discussions, whereby nurses were invited to revisit their experiences in light of new evidence. Slowly, trust in the process grew.
To further support this cultural shift, the team designed a clear, nurse-led protocol with specific assessment criteria, empowering bedside nurses to initiate ambulation safely and consistently. We worked closely with the cardiology team to ensure alignment and support, and built in structured post-implementation audits to track complications, patient comfort, and nurse confidence.
The results spoke volumes. Over the pilot period, no increase in vascular complications was observed between patients with radial and femoral access sites. More importantly, patient feedback improved significantly—many expressed that back pain and urinary discomfort decreased when being allowed to sit up and walk earlier. Nurses, too, reported greater satisfaction and clinical clarity, with one even sharing, “I used to feel anxious about letting patients move too early, but now I feel more in control, like I know what’s safe.”
The preliminary success of this initiative was anchored in a collaborative, multi-tiered leadership approach. The project team led the development of protocols and audit metrics, while ward nurses contributed real-time insights that shaped practical adjustments. One project lead shared:
“As a senior nurse, I saw how important it was to create a safe space for the team to ask questions and challenge long-standing habits. Leading this change wasn’t just about pushing a protocol — it was about guiding others to see the value of evidence, building their confidence, and showing that we can shape better outcomes together.”
When practice changes, people feel it
Following the implementation of early ambulation, the initiative brought benefits that extended well beyond patient outcomes. The incidence of moderate-to-severe back pain decreased from 40% to 10%, and urinary difficulty dropped dramatically from 60% to 6.2%, while vascular complications remained stable. These outcomes not only enhanced patient recovery and satisfaction but also pointed to reduced lengths of stay—contributing to improved cost-effectiveness for the hospital.
An informal nursing survey revealed that patient complaints about back pain and urinary discomfort fell sharply from 84.4% to 18.7%. For the nurses, it wasn’t just data, it represented relief: “It’s not just the patients who feel better—we do too. There’s less emotional tension, fewer bedpan struggles, and more time to focus on patient education or clinical assessments.”
Challenges and lessons learned
Despite these positive outcomes, documentation processes and concerns over patient safety were initial barriers to implementation among staff. “Initially, I was cautious about mobilising patients so soon after percutaneous coronary intervention, especially those with femoral access––what if something went wrong because we got patients up too early?”, admitted one staff nurse. “But after training and seeing the step-by-step protocol in action, I realised early ambulation actually reduced patient discomfort and didn't increase complications. It gave me more confidence in my clinical decision-making.” To address these challenges, continuous staff training, instilling project champions, creating open feedback channels, and initiating electronic templates were simultaneously integrated to refine the protocol. These cost-effective measures significantly improved nursing compliance and can be easily replicated in other healthcare settings.
Sustainability and future steps
Early ambulation after percutaneous coronary intervention has demonstrated significant benefits in improving patient outcomes and potentially reducing hospital stays. However, the impact extends beyond patient care. Early ambulation has become more than a protocol—it transformed post-procedure care into a nurse-led initiative. Reflecting on the journey, Ellene shares, “At the heart of this project was the simple goal of helping patients recover with more dignity and less discomfort. But along the way, we also rediscovered the power of nursing leadership. It reminded me—and hopefully others—that when nurses are given the tools, time, and trust to lead, we can transform care from the bedside outward.”
Image 1: Nurses behind the Early Ambulation after Coronary Angiographic Procedures in the Coronary Monitoring Unit
Moving forward, the team aims to expand this practice to a broader patient cohort within the hospital, further demonstrating the value of nurse-led initiatives in healthcare improvement. By leveraging JBI's Evidence Implementation Framework, nurses at the NUH are not only enhancing patient recovery but also strengthening their own professional capabilities and contributing to a more robust healthcare economy.
This experience reminded us of the true heart of evidence-based practice: it is not just about protocols—it is about the people. By bridging the gap between knowledge and action, nurses have the power to transform not only outcomes, but everyday experiences for patients and themselves. Our early ambulation project was a small step, literally and figuratively, but it was a step toward more responsive and sustainable care. And sometimes, that first step is the one that matters most.
Key messages
Prolonged bedrest duration after coronary angiographic procedures increases patient discomfort and delays recovery, yet is common due to nurses’ fears of complications and reliance on tradition over evidence.
Early ambulation at 4 hours after coronary angiographic procedures is proven to be safe, evidence-based, and significantly reduces patient back pain and urinary discomfort, thereby enhancing recovery without increasing vascular risk.
Challenges to implementation––such as documentation and safety concerns––were addressed with staff training, digital tools and project champions, ensuring sustainable change.
References
Omeh, D.J., & Shlofmitz, E. (2023). Angiography. StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557477/
Ahmad, M., Mehta, P., Reddivari, A. K. R., & Mungee, S. (2023). Angioplasty. Percutaneous Coronary Intervention. StatPearls. StatPearls Publishing. PMID: 32310583. https://doi.org/10.1016/J.Ijchv.2014.08.001
Dal Molin, A., Faggiano, F., Bertoncini, F., Buratti, G., Busca, E., Casarotto, R., Gaboardi, S., & Allara, E. (2015). Bed rest for preventing complications after transfemoral cardiac catheterisation: a protocol of systematic review and network meta-analysis. Syst Rev, 15;4:47. doi: 10.1186/s13643-015-0036-0. PMID: 25903277; PMCID: PMC4406333.
Lu, Y. Z., & Chuang, P. Y. (2018). Aching backs. Reducing the incidence of back pain in post-percutaneous coronary intervention patients with femoral sheath. Hu Li Za Zhi, 65(4):94-10. doi: 10.6224/JN.201808_65(4).12. PMID: 30066327.
Mahgoub, A., Mohamed, W., Mohammed, M., Abdel-Aziz, M., & Kishk, Y. (2013). Urinary retention. Impact of early ambulation on patients’ outcome post transfemoral coronary procedures, at Assiut University Hospital. Journal of Education and Practice, 4(28): 22-32.
Mohammady, M., Atoof, F., Sari, A. A., & Zolfaghari. M. (2014). CRIB durations varied drastically between six to 24 hours, without any clear consensus. Bed rest duration after sheath removal following percutaneous coronary interventions: a systematic review and meta-analysis. J Clin Nurs, (11-12):1476-85. doi: 10.1111/jocn.12313. PMID: 24028631.
To link to this article - DOI: https://doi.org/10.46658/JBIIM-25-09
Links to Additional Resources
JBI Manual for Evidence Implementation
Authors
Lim Ellene1,3
Tan Xiao Ting1
Tiong Jun Khai1
Jiang Yue1
Sho Adrienne1
Hu Shu Yuan1
Tho Poh Chi23
1. Nursing Division, National University Heart Centre, Singapore
2. Nursing Department, National University Hospital, Singapore
3. JBI Singapore National University Hospital Nursing Centre, University of Adelaide, Australia