Review literature for evidence regarding early ambulation in medical patients› Bed rest causes harm› Early ambulation helps

Discussion› Our problems at UNM› Moving forward:

Step 1: Work more effectively with status quo Discussion by Physical therapy and Occupational therapy

Step 2: Work towards what we want

Sources:•Kleinpell RM, Fletcher K, Jennings BM. Reducing functional decline in hospitalized elderly. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ); 2008:251Y265.•Truong, AD, et al. Bench-to-bedside review: Mobilizing patients in the intensive care unit – from pathophysiology to clinical trials. Critical Care 2009 , 13:216.

• Low mobility/bedrest is a common occurrence in hospitalized patients

• Functional decline is the leading complication of hospitalization for the elderly (occurs in 34-50% of hospitalized older adults)– Deconditioning and functional decline was found to occur by

day 2 of hospitalization– Comparison of functional status at baseline and day 2 in 71

hospitalized pts >age 74 showed declining ability in: mobility, transfer, toileting, feeding, and grooming.

Deconditioning + physiologic changes 2/2 bed rest declining ability to perform ADLs / functional decline› Functional decline increased LOS, increased mortality,

increased institutionalization and need for longer rehab and home health services, increased healthcare costs.

This leads to previously independent patients being d/c’d to SNF!

Source:•Kleinpell RM, Fletcher K, Jennings BM. Reducing functional decline in hospitalized elderly. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ); 2008:251Y265.

Older people who develop new functional deficits during hospitalization are less likely to recover lost function.

One study: 1279 older adults (>70yrs) hospitalized for acute medical illness. › 31% had decline in ADLs at discharge

compared with pre-admission baseline. › At 3 months, 51% of original study sample

reported new ADL/IADL disabilities (40%) compared with pre-admission, and 11% had died.

Source:•Sager MA, Franke T, Inouye SK, et al. Functional outcomes of acute medical illness and hospitalization in older persons. Arch Intern Med. 1996;156(6):645–652.

Bed rest can contribute to development of delirium.

Delirium is independently associated with worse outcomes, longer hospital stay, higher cost, increased risk of death, and with greater degrees of cognitive decline.

Delirium increased risk of needing d/c to SNF!

Source:Banerjeea A, et al. The complex interplay between delirium, sedation, and early mobility during critical illness: applications in the trauma unit. Current Opinion in Anesthesiology 2011,24:195–201.

Study of 162 pts, age >/= 65, admitted for acute illness, hospital stay at least 2 days.

Placed step activity monitors on all pts. Calculated step change score between day 1 and day 2.

Results: Adjusted mean difference in LOS between those who increased their step total by >/= 600 steps was 2.13 days (95% CI, 1.05-3.97).

600 steps corresponds to approx 12 min of slow walking.

Limitations: observational only. Pts who increased their step count may have been less ill.

Source: Fisher SR, et al. Early Ambulation and Length of Stay in Older Adults Hospitalized for Acute Illness. Arch Intern Med. 2010 November 22; 170(21): 1942–1943.

Study looked at 458 pts with CAP admitted to medicine wards (3 hospitals).

Group randomized trial Intervention: EM defined as sitting OOB or ambulation

at least 20 min within 1st 24 hrs of hospitalization, with progressive mobilization on each subsequent hospital day

Results: next slide. Also noted non-statistically significant decrease in hospital costs, approx $1000 per pt.

Conclusions: EM of hospitalized patients with CAP reduces overall hospital length of stay and institutional resources without increasing the risk of adverse outcomes.

Source: Mundy, LM, et al. Early Mobilization of Patients Hospitalized With Community-Acquired Pneumonia. CHEST 2003; 124:883–889.

Results: › Intervention and control groups were similar: age,

gender, disease severity, door-to-drug delivery time, IV-to-po switchover time.

› Hospital LOS significantly less (mean, 5.8 vs 6.9 days; adjusted absolute difference, 1.1 days; 95% confidence interval, 0.0 to 2.2 days).

› There were no differences in adverse events or other secondary outcomes (mortality, re-admissions, ED visits, #CXRs) between treatment groups.

Study with n= 50 pts, adults >/= 60 yrs, admitted with medical dx, LOS 3+ days, cognitively intact, no significant physical impairments.

Compared 2 units (no RNs crossed units). Intervention: RNs on tx unit had training

including mobility protocol. • Measures: Calculated modified Barthel Index (BI)-

measures capability to do ADLs/functional status and Up and Go test. Also looked at LOS.

Source: Padula CA, et. al. Impact of a nurse-driven mobility protocol on functional decline in hospitalized older adults. J Nurs Care Qual. 2009 Oct-Dec;24(4):325-31.

•Scores for Up and Go test not significantly different between groups (Treatment group: 1.16 admission, 1.04 discharge. Control: 1.35 admission, 1.17 discharge.)

•Treatment group: significantly shorter LOS (4.96 days treatment vs 8.72 days control; P<0.001)

RCT with 45 pts with DVT, some did early ambulation.

Participants who performed early ambulation exercises had:› Lower overall pain scores.› Significant reduction in leg swelling (lower leg circumference). › Reported significantly improved clinical symptoms including less

pain during walking, reduced pain associated with the sole of the foot and palpation of the foot.

› Less subfascial edema, prefascial edema, a lower skin temperature, and reduced redness/cyanosis of the affected limb.

Long-term follow-up study of 37 of the 45 original medical patients (2 yrs later).

Although not statically significant, a lower percentage of patients in the early ambulation group had swelling (increased leg circumference) in the affected limb (16/26 early ambulation group vs 9/11 in the bed-rest group).

A significantly lower percentage of patients in the early ambulation group (18/26 vs 2/11 in the bed-rest group) had no symptoms of post-thrombotic syndrome (a significant complication of DVT).

Sources•Partsch H, Blattler W. Compression and walking versus bed rest in the treatment of proximal deep venous thrombosis with low molecular weight heparin. J Vasc Surg. 2000;32:861Y869.

•Partsch H, et al. Immediate mobilization in acute vein thrombosis reduces post-thrombotic syndrome. Int Angiol. 2004;23(3):206Y213.

Study: quality improvement project; evaluated 6 mo period on unit pre- and post-intervention. All pts for colorectal and urologic surgeries with no contraindication for ambulation included (n= 1878 pre-intervention, n= 1748 post-intervention).

Intervention: Revising orders, measuring/posting distances on the units, creating fields in EMR to display ambulation distances, education of staff, improving dashboard on EMR for easy monitoring of ambulation.

Results:

Note: no increase in falls

A 37% decrease in paralytic ileus represents potential annual cost savings of $830,000

Source: Kibler VA, et. al. Early Postoperative Ambulation: Back to Basics. AJN. April 2012; 112(4): 63-69.

Study: pts admitted to NSI in 10-mo pre-intervention and 6-mo post-intervention period. Intervention: comprehensive mobility initiative utilizing the Progressive Upright Mobility

Protocol (PUMP) Plus. Results:

› Implementation of the PUMP Plus increased mobility among neurointensive care unit patients by 300% (p < 0.0001).

› Reduction in neurointensive care unit length of stay (LOS; p < 0.004), hospital LOS (p < 0.004), hospital-acquired infections (p < 0.05), and ventilator-associated pneumonias (p < 0.001), and decreased the number of patient days in restraints (p < 0.05).

› Additionally, increased mobility did not lead to increases in adverse events as measured by falls or inadvertent line disconnections.

Source: Titsworth WL, et. al. The effect of increased mobility and morbidity in the neurointensive care unit. J Neurosurg 116:1379–1388, 2012.

No difference in falls

Decreased LOS Decreased hospital complications Decreased cost Improved quality of life (and less d/c to

SNF)

Implementation does not require significant cost, and does not cause any adverse effects (e.g. no increase in falls - may even prevent falls).

UNM has longer LOS for similar diagnosis compared to other hospitals.

MDs focus on treatment (meds) Hospital culture with decreased focus on

mobility/functional status most of our medicine patients stay in bed› We keep patients in bed for fear of increased falls

Our patients develop functional decline over hospital course. Often MD does not notice until day of d/c prolonged stay, more pts need placement.

Over-reliance on PT for ambulation. In most hospitals, this is RN-driven initiative.

Other thoughts?

On 7 medicine teams, 8 patients reported to be remaining in the hospital “solely for PT/OT needs.”

PT/OT input on how we can help them maximize their impact

Ideas on how to achieve this?› What can we as providers do?› What system processes can we

implement?

Most likely RN-driven mobility protocols› Utilizing techs or other support staff for

ambulation› Utilizing PT/OT for more complex issues

Things MDs can do to help:› Activity orders- don’t write bed rest› D/c Foley› Judicious use of telemetry (we lack wireless

telemetry)› Don’t keep isolation patients in their rooms

(they can walk with gowns)

Kleinpell RM, Fletcher K, Jennings BM. Reducing functional decline in hospitalized elderly. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ); 2008:251Y265.

Truong, AD, et al. Bench-to-bedside review: Mobilizing patients in the intensive care unit – from pathophysiology to clinical trials. Critical Care 2009 , 13:216.

Banerjeea A, et al. The complex interplay between delirium, sedation, and early mobility during critical illness: applications in the trauma unit. Current Opinion in Anesthesiology 2011,24:195–201.

Mundy, LM, et al. Early Mobilization of Patients Hospitalized With Community-Acquired Pneumonia. CHEST 2003; 124:883–889.

Aissaoui N, et al. A meta-analysis of bed rest versus early ambulation in the management of pulmonary embolism, deep vein thrombosis, or both. Int J Cardiol. 2009 Sep 11;137(1):37-41. Epub 2008 Aug 8.

Partsch H, Blattler W. Compression and walking versus bed rest in the treatment of proximal deep venous thrombosis with low molecular weight heparin. J Vasc Surg. 2000;32:861Y869.

Partsch H, et al. Immediate mobilization in acute vein thrombosis reduces post-thrombotic syndrome. Int Angiol. 2004;23(3):206Y213.

Sager MA, Franke T, Inouye SK, et al. Functional outcomes of acute medical illness and hospitalization in older persons. Arch Intern Med. 1996;156(6):645–652.

Fisher SR, et al. Early Ambulation and Length of Stay in Older Adults Hospitalized for Acute Illness. Arch Intern Med. 2010 November 22; 170(21): 1942–1943.

Padula CA, et. al. Impact of a nurse-driven mobility protocol on functional decline in hospitalized older adults. J Nurs Care Qual. 2009 Oct-Dec;24(4):325-31.

Kibler VA, et. al. Early Postoperative Ambulation: Back to Basics. AJN. April 2012; 112(4): 63-69. Titsworth WL, et. al. The effect of increased mobility and morbidity in the neurointensive care unit. J

Neurosurg 116:1379–1388, 2012. Pashikanti L, Von Ah D. Impact of Early Mobilization Protocol on the Medical-Surgical Inpatient

Population. Clin Nurse Spec. 2012 Mar-Apr;26(2):87-94.

Aissaoui N, et al. A meta-analysis of bed rest versus early ambulation in the management of pulmonary embolism, deep vein thrombosis, or both. Int J Cardiol. 2009 Sep 11;137(1):37-41. Epub 2008 Aug 8. › Meta-analysis of 5 studies comparing outcomes of pts with DVT, PE, or both

managed with bed rest vs early ambulation in addition to anticoagulation.› RESULTS: The 5 studies retained in this analysis included a total of 3048

patients. When compared to bed rest, early ambulation was not associated with a higher incidence of a new PE (RR 1.03; 95% CI 0.65-1.63; p=0.90). Furthermore, early ambulation was associated with a trend toward a lower incidence of new PE and new or progression of DVT than bed rest (RR 0.79; 95% CI 0.55-1.14; p=0.21) and lower incidence of new PE and overall mortality (RR 0.79; 95% CI 0.402-1.56; p=0.50).

› CONCLUSIONS: Compared with bed rest, early ambulation of patients with DVT, PE or both, was not associated with a higher risk of progression of DVT, new PE or death. This meta-analysis does not support the systematic recommendation of bed rest as part of the early management of patients presenting with DVT, PE of both.