|Back to Basics: Emphasizing Progressive Mobility in the Inpatient Setting|
Evidence suggests that inpatient mobilization, defined as an individual’s ability to walk, stand, or sit in a chair without assistance during a hospital stay, is an essential part of recovery. Emphasizing mobility has proven to yield physical, psychological, and social benefits for patients, including: fewer post-operative complications, increased levels of patient autonomy, and decreased anxiety and stress among caregivers (Kalish, Lee, & Dabney, 2014). Despite this, mobilization has been identified in peer-reviewed literature as one of the most frequently missed elements of inpatient nursing care (King, 2012). During an extensive observational study conducted by Kuys, Dolecka, and Guard (2011), patients were documented as “inactive” for more than 75% of their hospital stay.
Best-practice for mobilization, depending on the patient’s condition and baseline activity level, is to ambulate patients (i.e., move from one place to another) at least three times per day with incrementally decreasing levels of assistance (Pashikanti & Von, 2012). Bedrest, the common alternative to consistent ambulation, can have detrimental effects to nearly every body system. Inpatient mobilization is particularly important among the geriatric population. Functional decline (or decrease in patient’s baseline mobility status) can occur as early as the day two of a hospital admission among patients aged 65 and older (Pashikanti & Von, 2012). Among this group, one-third of hospitalized older adults will encounter decreases in activity of daily living (ADL) during their time in the hospital; half of these individuals will never regain that lost function (Liu et al, 2013).
Measuring and improving levels of inpatient mobility, particularly among the geriatric population, is a pretty consistent quality improvement priority among hospitals in developed nations. Large-scale, multi-site studies on inpatient mobilization have been conducted in the United States, Canada, Australia and the United Kingdom (Kneafsey, Clifford, & Greenfield, 2014; Liu et al, 2013; Cattanach et al, 2014). We need to ensure we are replicating these processes at our local facilities. Currently, older adults currently represent 15.6% of the state population, proportionally 2.6% more than the rest of the nation (Hawaiʻi Health Matters, 2013). Compared to our mainland counterparts, older adults in the state of Hawaiʻi are more likely to live at home because of the limited of skilled-nursing facility resources and because of the regional norm of multi-generational homes. Accordingly, mobility efforts need to not only focus on patients’ in-house ambulation, on but educating their caregivers on post-discharge physical activity expectations as well.
There is an abundance of evidence-based literature available that shows that ambulation is a cost-effective way to improve patient outcomes regardless of their age, diagnosis, or level-of-care (Kalish, Lee, & Dabney, 2014). There are qualitative studies to assess: how nurses decide to whether to mobilize a patient, how often patients expect to move during hospitalization, and what motivates providers or family members to take responsibility for mobilizing patients (Doherty-King & Bowers, 2011, Cattanach et al, 2015, Doherty-King & Bowers, 2013). Despite this, there are several remaining gaps in the literature around the inpatient mobilization process. Most notably, there are very few studies that examine the sustainability of these interventions at the individual, interpersonal, and organizational levels.
To address this gap, we should seek to understand who currently responsibility for mobilization and challenge providers to consider how ambulation can be seamlessly integrated into their workflows. We need to pursue creative ways to measure and document ambulation in electronic record systems; this will allow us to more definitively attribute mobility efforts to improved patient outcomes and cost-savings. We need to understand how to best equip patients and families to comply with activity recommendations post-discharge, so that the patients’ functional status is maintained. As healthcare executives, we should strive cultivate a lasting culture of mobility throughout the continuum of care.
Cattanach, N., Sheedy, R., Gill, S., & Hughes, A. (2014). Physical activity levels and patients' expectations of physical activity during acute general medical admission. Internal Medicine Journal, 44(5), 501-504.
Doherty-King, B., & Bowers, B. J. (2013). Attributing the responsibility for ambulating patients: a qualitative study. International journal of nursing studies, 50(9), 1240-1246.
Doherty-King, B., & Bowers, B. (2011). How nurses decide to ambulate hospitalized older adults: development of a conceptual model. The Gerontologist, 51(6), 786-797.
Hawaiʻi Health Matters (2013). The Healthy Communities Network. Available at: http://www.Hawaiʻi healthmatters.org/modules. Honolulu, Hawai‘i: Hawai‘i Department of Health. Accessed: 08 September 2015.
Kalisch, B. J., Lee, S., & Dabney, B. W. (2014). Outcomes of inpatient mobilization: a literature review. Journal of Clinical Nursing, 23(11-12), 1486-1501.
King, Lisa (2012). Developing a Progressive Activity Protocol. Orthopaedic Nursing, 31 (5), 253-261.
Kneafsey, R., Clifford, C., & Greenfield, S. (2015). Perceptions of hospital manual handling policy and impact on nursing team involvement in promoting patients’ mobility. Journal of Clinical Nursing, 24(1-2), 289-299.
Kuys, S. S., Dolecka, U. E., & Guard, A. (2012). Activity level of hospital medical inpatients: An observational study. Archives of Gerontology and Geriatrics, 55(2), 417-421.
Liu, B., Almaawiy, U., Moore, J., Chan, W., Straus, S, and the MOVE ON Team (2013). Evaluation of a multisite educational intervention to improve mobilization of older patients in hospital: protocol for mobilization of vulnerable elders in Ontario. Implementation Science. 8 (76), 1-8.
Mundy, L. M., Leet, T. L., Darst, K., Schnitzler, M. A., & Dunagan, W. C. (2003). Early mobilization of patients hospitalized with community-acquired pneumonia. CHEST Journal, 124(3), 883-889.
Padula, C. A., Hughes, C., & Baumhover, L. (2009). Impact of a Nurse‐Driven Mobility Protocol on Functional Decline in Hospitalized Older Adults. Journal of Nursing Care Quality, 24(4), 325-331.
Pashikanti & Van (2012) Impact of Early Mobilization Protocol on the Medical-Surgical Inpatient Population: An Integrated Review of the Literatrue. Clinical Nurse Specialist, 26(2), 87-94.