• cardiac rehabilitation;
  • continuity of care;
  • interdisciplinary team;
  • postoperative care

Quite often nurses in environments other than the immediate postoperative setting are responsible for the well-being of patients who have had open-heart surgery (OHS). These patients may be admitted to rehabilitation or home healthcare settings as early as 1 week after surgery. They may be deconditioned because of postoperative complications such as a cerebrovascular accident or cardiopulmonary compromise. Rehabilitation nurses in inpatient or home health environments are key members of the interdisciplinary team in terms of establishing standards of care for OHS patients after surgery. Coordinating care within an interdisciplinary team reduces fragmentation of care, improves patient outcomes, and enhances patient, family, staff, and physician satisfaction. This article focuses on empowering rehabilitation nurses as leaders and members of interdisciplinary teams as they establish standards for coordinating the postoperative care of OHS patients.