INCREASING MOBILITY IN THE HOSPITAL SETTING
Cynthia J. Brown, MD, MSPHGwen McWhorter, Ed.D., Endowed Chair in Geriatric Medicine
Director, Division of Gerontology, Geriatrics, and Palliative CareDirector, Comprehensive Center for Healthy Aging
Vice Chair, Faculty and Staff Development, Dept of Medicine
OBJECTIVES/ DISCLOSURES
After attendance at this lecture, participants will be able to:1. Describe prevalence and outcomes of hospital-associated
disability.2. Summarize interventions that have been successfully used in
the hospital setting to increase mobility.3. Define elements needed to create the necessary culture
change to promote hospital mobility
No disclosures to report
CONSEQUENCES OF LOW MOBILITY
• Many observed geriatric syndromes related to bed rest and low mobility during hospitalization:• Delirium• Pressure Ulcers• ADL Decline• Incontinence• Falls
STUDY OF MOBILITY: THE EARLY YEARS
Pre-2005, limited methods to measure mobility• Chart review of physician activity orders1
• Brief surveys of patient location2
• Periodic nursing reports3
• Direct observation of hallways4
In 2009, first paper published using accelerometers5
1 Lazarus BA, et al. Arch Intern Med, 1991; 2 Warshaw G, et al. JAMA 1982; 3 Brown CJ, et al. J Am Geriatr Soc, 2004;4 Callen BL, et al. Geriatr Nurs 2004; 5 Brown CJ, et al. J Am Geriatr Soc, 2009
DEFINITION AND FREQUENCY OF LOW MOBILITY
• Low mobility, defined as bed rest or bed to chair activity, common during hospitalization.
• 83% of hospital stay spent in bed• 43 min/day spent standing/walking; Results
duplicated
Brown CJ, et al. JAGS 2009
Patient-related factorsIllness severity
Comorbid conditionsAltered mental statusPatients symptoms
Institution-related factorsStaffing patterns
Environment encourages bed restLack of ambulatory devices
Treatment-related factorsHospital devices
Admitting diagnosisSide effects of medications
Attitudinal factorsAttitude toward mobility
Expectation of hospital stayConcern about falls
PATIENT
MODEL OF POTENTIAL BARRIERS
Brown CJ, et al. J Hosp Med, 2009
BARRIER: ENVIRONMENT
“I think it is just that patients, when they are in the hospital, they feel they are supposed to be in bed. And they are more comfortable there and a lot of times they can see the TV better.”
- a Doctor
PREVALENCE AND OUTCOMES
• 498 hospitalized medical patients, age ≥ 70 years• Mobility scale based on nurse report:
–degree of assistance needed –number of times transferred and ambulated
• Average of mobility observations for each patient, scores trichotomized–Low mobility: bed rest or bed to chair– Intermediate mobility–High mobility
Brown CJ, Friedkin RJ, Inouye SK. J Am Geriatr Soc. 2004.
IMPACT OF 10 DAYS OF BED REST IN HEALTHY OLDER ADULTS
Test Pre-Bed Rest
Post-Bed Rest
% Change P value
Knee ExtensionIsometric (N)
144.7 ± 15.1 117.6 ± 13.6 -11.2 ± 3.9 .017
Concentric (N·m/s) 69.9 ± 8.1 60.1 ± 7.0 -13.5 ± 4.4 .011Knee Flexion
Isometric (N)76.8 ±10.0 68.1 ± 10.5 -14.2 ± 3.6 .003
Concentric (N·m/s) 80.3 ± 8.8 71.6 ± 9.4 -11.8 ± 4.6 .03
DEXA Lean Mass, kg
Lower Extremity 15.01 (12.41 to
17.61)
14.06 (11.85 to 16.27)
-0.95 (-0.42 to -
1.48)
.003
% Change -6.3 (-3.1 to -9.5)
Kortebein P, et al. J Gerontol Med Sci , 2008; Kortebein P, et al. JAMA 2007
BEYOND FUNCTIONAL DECLINE
Study of Aging I:1000 Subjects, stratified, random sample of Medicare beneficiaries living in 5 counties in central Alabama
Study over-sampled males, African Americans, and rural residents
Autauga
Baldwin
Barbour
Bibb
Blount
Bullock
Butler
Calhoun
Chambers
Cherokee
Chilton
Choctaw
Clarke
Clay
Cleburne
Coffee
Colbert
Conecuh
Coosa
Covington
Crenshaw
Cullman
Dale
Dallas
De Kalb
Elmore
Escambia
Etowah
Fayette
Franklin
Geneva
GreeneHale
Henry
Houston
Jackson
Jefferson
Lamar
Lauderdale
Lawrence
Lee
Limestone
Lowndes
Macon
Madison
Marengo
Marion
Marshall
Mobile
Monroe
Montgomery
Morgan
Perry
Pickens
Pike
Randolph
Russell
Saint Clair
Shelby
Sumter
Talladega
Tallapoosa
Tuscaloosa
Walker
Washington
Wilcox
Winston
Urban CountiesRural Counties
ALABAMA
Life-Space asks in last 4 weeks: • how far travelled• frequency of travel• need for
assistance from equipment or another person
Scores range 0-120.
Well validated in person and by telephone
Bedroom
Home
Neighborhood
Town
Out of Town
Yard
MEASURING LIFE-SPACE
Sawyer P, et al. JAGS 2003
METHODS
• 211 hospitalizations among 687 participants over 4 years• Surgical admissions = 44; • Non-surgical admissions = 167
• Life-Space Assessment every 6 months• Using multilevel change model to determined
trajectory of Life-Space before and after hospitalization.
PREVIOUS OUT OF BED PROTOCOLS
• Transporters used to walk patients during quiet periods, especially nights, week-ends1
–Pilot study, demonstrated feasibility only• Nurse driven protocol of progressive
ambulation among patients with pneumonia2
–No functional outcomes assessed
1 Tucker D, et al. Geriatr Nurs. 2004 2 Mundy, et al. Chest, 2003
MOBILIZING OLDER ADULT PATIENTS VIANURSE-DRIVEN INTERVENTION (MOVIN)
Nurse-driven intervention with 5 components: Psychomotor skills training for nurses Increase self-efficacy in determining safety for ambulation
Communication tools White boards for information sharing
Ambulation pathways Pathways with visual markers to measure distance/ add
interest
Ambulation resources Both human and equipment to maximize ambulation
Ambulation culture Establish nurse ownership and sustainability of patient
ambulationKing B, et al, JAGS 2016
SAFETY AND EFFICACY OF A HOSPITAL MOBILITY PROGRAM
• 100 patients from Birmingham VAMC–Not delirious or demented, walking 2 weeks
PTA• Randomly assigned to Mobility Program (MP)
or Usual Care (UC)• Assessments by blinded assessors• One month telephone follow-up• Physicians blinded to assure no change in
usual care (e.g. activity orders, PT consults)
Brown CJ, et al. JAMA Intern Med, 2016
Mobility Program (MP)•Twice daily walks with assistance
•Provision of rolling walker, if needed & safe
•Provision of folder; document goals; track sitting, walking
•Daily motivational interviewing; focus on goals & barriers
Usual Care (UC)•Twice daily friendly visits
•Provision of folders; document friendly messages and track visitors
METHODS
BASELINE CHARACTERISTICS
N = 100 Usual CareWalking Program P value
Age 73.4 ± 7.0 74.4 ± 6.9 0.48Gender, male 49 (98%) 48 (96%) 0.56Race, black 8 (16%) 11 (22%) 0.44LOS, mean 3.6 ± 2.4 4.6 ± 4.0 0.13
median 3.0 3.0GDS 5.0 ± 3.0 4.7 ± 3.2 0.63Charleson Comorbidity 4.1 ± 2.6 4.4 ± 2.4 0.55APACHE 15.3 ± 11.8 14.3 ± 10.6 0.67PT Ordered 17 (34%) 24 (48%) 0.15
MOBILITY TECHS TO INCREASE MOBILITY
• Showed provision of mobility by techs feasible and safe.• 3 in-hospital falls, all in control group
• No change in ADLs; community mobility maintained in MP, and declined in UC.
Usual CareMobility Program P value
Baseline LSA 51.5 (21.1) 53.9 (29.4) 0.4
Post-Hospital LSA 41.6 (21.5) 52.5 (29.0) .0096
P-values for group differences between pre and post hospital outcomes adjusted for baseline, age, gender, race
MOBILITY ASSESSMENTS
Attaching monitors not practical due to time and expense.Need method to measure mobility on all hospitalized patients.One available assessment relies on nurse observation of patient mobility. Johns Hopkins Highest Level of Mobility Scale
Hoyer E, J Hosp Med, 2016
VALIDATION OF THE ACUTE CARE MOBILITY ASSESSMENT (ACMA)
• Study Purpose: validate brief self-reported mobility assessment to measure frequency of out-of-bed activity during hospitalization.
• Recruitment:• Cognitively intact hospitalized adults age ≥ 65 years• Able to walk prior to admission
• 63 consented, 12 not used in analysis • lack of at least 22 hours of StepWatch data (n=10) • lack of patient data due to transfer to higher level of
care (n=2)• Accelerometer (StepWatch) worn for 24 hours • Assessments completed after accelerometer data
collected
ASSESSMENTS
Patients• Age• Self-identified gender &
race/ethnicity• Acute Care Mobility
Assessment
Medical Records• Charlson Comorbidity Index
Nurses• Katz index (prior to
admission; current)• Johns Hopkins Highest Level
of Mobility Scale
AnalysisUsed Spearman correlation coefficient comparing steps taken and time spent walking with ACMA and JH-HLM scale
BASELINE CHARACTERISTICS
Characteristics (N=51) Mean (SD) or N (%)
Age, years, mean (SD) 74.3 (6.2)Self-identified Gender
FemaleMale
32 (63%)19 (37%)
Self-identified RaceAfrican-American WhiteAsian
29 (57%)20 (39%)2 (4%)
Katz ADL Score Prior to Admission, mean (SD), n=49 11.4 (2.0)Katz ADL Score at Study Entry, mean (SD), n=49 10.3 (2.9)Charlson Comorbidity Index, mean (SD) 1.98 (1.9)Steps Taken, mean (SD)
Range660 (662) 10 - 2831
Johns Hopkins-Highest Level of Mobility Score (n=43) 6.0 (1.3)
PROPORTION OF PATIENTS ACHIEVING EACH LEVEL
N (%) 1X 2X 3X ≥4XSat in chair or side of bed 51
(100%)4
(8%)4
(8%)5
(10%)38
(74%)
Walked in room 51 (100%)
2 (4%)
6 (12%)
4 (8%)
39 (76%)
Walked in hallway 25 (49%)
9 (18%)
4 (8%)
6 (12%)
6 (12%)
Walked off the unit 6 (12%)
2 (4%)
2 (4%)
2 (4%)
0
SPEARMAN CORRELATION
ACMA r p-value JH-HLM r p-valueTotal # of Steps 0.84 <.0001 0.64 <.0001
Total Time Walking 0.67 <.0001 0.54 0.0002
JH-HLM scale 0.59 <.0001
• Most highly correlated included only levels with walking;
• Did not include sitting or need for help.
STRENGTHS/ LIMITATIONS
Strengths:• Done in general medical population, not limited by
disease. • Representation of both genders and white/black (but
not other race/ethnicities). • Easy to complete, takes less than 3 minutes to get
information. Limitations:• Patients have to be cognitively intact enough to
complete scale• Not perfect correlation. • Not tied to outcomes (yet).
CULTURE CHANGE AROUND MOBILITY
Three key elements to culture change:• Team members must be able to articulate
what being proposed.• Team members need to understand the
“Why”.• Leaders define role of team members.
BARRIERS TO HOSPITAL MOBILITY CULTURE CHANGE
• Ownership of mobility unclear • Hospital culture encourages low mobility• Hospital environment encourages low mobility• Healthcare Policy encourages low mobility
OWNERSHIP OF HOSPITAL MOBILITY UNCLEAR
Physical Therapy: • Too few PTs to walk hospitalized patients; often not
skilled needNursing:
• Responsibilities increased significantly; more documentation, less patient care time.
• Many report not feeling comfortable walking patientsFamily:
• Need education and trainingVolunteers:
• Successful in programs like HELP; need robust training program
Transporters: • Successful in small pilot study; have other job
responsibilities
RE-ENVISIONING HOSPITAL ROOM DESIGN
2017 Environment for Aging (EFA) ConferenceBarbara Miszkiel OAA, MRAIC, LEED AP, EDAC and colleagues
GLOBAL POLICIES ENCOURAGE LOW MOBILITY
• Safety/ Fall Prevention• Falls with injury a “Never Event” per CMS in 20081
• Hospitals responded with robust Fall Prevention programs
• Key components of most fall prevention programs:• Patient to call for assistance prior to out of bed• Patient education regarding fall
prevention• Patient identification as fall risks• Bed and chair alarms
1Inouye, Brown, Tinetti. NEJM 2009
MOBILITY AS QUALITY INDICATOR
• Change focus from Fall Prevention to Safe Mobility• AGS published white paper recommending mobility
as QI measure• Centers for Medicare and Medicaid Innovation
project targets mobility in 300+ hospitals
• John A. Hartford Foundation’s Age-Friendly Health System includes Mobility as one of 4 M’s
UAB MOBILITY INITIATIVE
• Phase 1: Staff education via UAB Learning System• Phase 2: Train-the-Trainers; Focused on coaching• Phase 3: Unit coaching by trainers/championso Address gaps identified by nurse managero 1:1 or group coaching on addressing barrierso Mobility leaders spot check, provide feedback
• Phase 4: Sustainmento “Booster” education provided by mobility teamo Accountability monitoring by Directors, Managerso Mobility in Nursing/PCT orientationo Gait Belt training as part of annual comps
Slides courtesy of Helen Matthews, PT and Kellie Flood, MD
TAKE HOME POINTS
• Older adults spend significant proportion of hospital stay in bed.
• Many barriers to hospital mobility modifiable.
• Mobility programs have been shown to be feasible, safe and efficacious.
• Culture change is required to integrate hospital mobility as a best practice.
INCREASING MOBILITY IN THE HOSPITAL SETTING
Cynthia J. Brown, MD, MSPHGwen McWhorter, Ed.D., Endowed Chair in Geriatric Medicine
Director, Division of Gerontology, Geriatrics, and Palliative CareDirector, Comprehensive Center for Healthy Aging
Vice Chair, Faculty and Staff Development, Dept of [email protected]