Mobility Plan Gets Hospitalized Patients Moving

Veronica Hackethal, MD

July 17, 2018

Extended bedrest is known to cause disability among hospitalized patients. Using a mobility plan can reduce the effects, hospitalists at the University of Pennsylvania say.

"Our clinical experience leads us to believe that the existence of a thoughtful plan to address functional status and mobility during and after hospitalization could help reduce the number of discharges to skilled-nursing facilities, enhance patient engagement and experience, and perhaps even influence postdischarge outcomes of care," write S. Ryan Greysen, MD, MHS, and Mitesh S. Patel, MD, MBA, from the University of Pennsylvania, Philadelphia.

They describe the overall goals of a mobility plan as well as the patient mobility guide currently used at Penn hospitals in an article published online July 16 in the Annals of Internal Medicine.

Patients older than 65 years are particularly vulnerable to the toxic effects of bedrest, with about 1 in 3 suffering loss of independence in activities of daily living after hospitalization.

Yet recent studies have found that taking as few as 1000 steps per day while hospitalized can make a big difference. The problem is that most hospitalized patients rarely leave their beds.

The authors recommend several ways in which hospitalists can help improve the situation. First, hospitalists should assess a patient's level of mobility at admission to establish baseline functioning and help set goals. This information can come from patients, family members, and review of the chart and nursing admission assessments.

Second, hospitalists should use that information to formulate a specific mobility plan. Such a plan should be drawn up at admission and not wait until hospital discharge. It should address daily goals such as time out of bed and appropriate level of walking for each patient.

To ensure implementation of the plan, hospitalists can write activity orders and integrate discussion of the plan on daily rounds with patients and nurses. Orders for bedrest should only be written for patients who are permanently disabled at baseline. Because physical and occupational therapy staff can be in short supply, consults for their services should be reserved for patients who need skilled rehabilitation.

The five-level mobility guide used at the Hospital of the University of Pennsylvania describes daily mobility goals for a range of patients, from permanently bedbound to fully ambulatory. For example, a patient who is fully ambulatory at baseline should walk in the halls at least three times daily, spend 90% of her awake time in a chair or walking, and 10% of her day in bed.

Even for a patient who is largely confined to bed at baseline, the guide recommends a goal of 10% of awake time spent in a chair or for 30 minutes three times per day.

"Assessment of functional status and mobility on admission and throughout the hospitalization must become our new norm. It's time for hospitalists to take a leading role in promoting patient mobility in the hospital to neutralize the toxicity of bedrest," Greysen and Patel conclude.

Such a mobility plan is a "strong idea" and "realistic," according to Steven Fisher, PhD, PT, an associate professor at University of Texas Medical Branch in Galveston.

"Everything that's mentioned in this article is out there in the literature and would be considered best practices. I think the recommendations in that article are practical and not particularly expensive approaches," said Fisher, whose own research focuses on older patient mobility, physical functioning during illness, and associated adverse outcomes.

Certain factors may stand in the way, Fisher acknowledges. These include institutional issues, such as the current emphasis on decreasing length of stay and the sheer lack of available physical therapists to mobilize patients.

"The best approach is to incorporate some of these models where they use mobility aids or less skilled personnel to mobilize these patients. That's recognizing the importance of simple ambulation in the context of acute illness," he said.

Family members and other caregivers can also play an important role in helping patients to mobilize, he added.

Ideally, he would like stronger evidence about thresholds for steps per day for specific kinds of acute illness. That would help providers know how much mobility is protective, how much may be harmful, and how much has only a marginal effect on outcomes.

"Lacking this kind of evidence, recommendations like this are the best we can do right now," he said.

Patel reports personal fees and/or other support from Catalyst Health, HealthMine Services INce,, and/or from Holistic Industries. Greysen and Fisher have disclosed no relevant financial relationships.

Ann Intern Med. Published online July 16, 2018. Extract

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