Ensuring the safety, well-being, and positive outcome of hospitalized mobility patients.
Early mobilization and safe handling of hospitalized patients are critical in reducing hospital-acquired complications.1,2 In addition to decreasing the possibility of adverse outcomes, these practices promote the overall well-being of patients while decreasing length of stay (LOS).3,4 The purpose of this article is to articulate an interdisciplinary approach that optimizes benefits of early mobilization.
East Jefferson General Hospital (EJGH), a community-owned hospital licensed for 448 beds, is located in southeastern Louisiana. This full-service hospital is a significant contributor to the economic and social vitality of its community. The governance of this not-for-profit hospital is a 10-member volunteer Board of Directors appointed by the parish president and council. The Medical Staff operates as an open staff that includes nearly 900 physicians. The hospital employs more than 3,200 team members including 725 full-time registered nurses. It has maintained Magnet status since 2002; and was honored as the first Magnet hospital in the state.
The Mobility Team was formulated in February 2009 after Care Management identified areas for improvement in length of stay possibly related to decreased mobility. Decreased mobility increases patient risks for deep vein thrombosis (DVT), falls, pressure ulcers, and other medical issues.4 Decreased mobility, particularly in the elderly and morbidly obese, contributes greatly to increased length of stay.3,5 Lack of physician activity orders further delays early mobilization. Untimely therapy consults also may lead to additional delays in the assessment and treatment of patients due to impaired mobility. In addition to the human toll, Medicare penalties for patients who experience adverse outcomes negatively impact health care financials.
Care Management, the department that handles case management for the facility, presented a proposal to the hospital Quality Council that outlined the establishment of a team (Mobility Team) to further examine opportunities for improvement related to early mobilization. The Quality Council members unanimously approved the request and an interdisciplinary team was established (see Figure 1). This interdisciplinary team included a physician champion, an administrator, and representatives from nursing, occupational and physical therapy, information technology, quality, care management, and patient transport.
The Mobility Team developed a charter with the purpose of a prospective movement toward mobilizing patients to decrease adverse outcomes and subsequently decrease length of stay. The focus was on all populations, specifically elderly and obese patients admitted to any inpatient nursing unit.
REVIEW OF THE LITERATURE
A detailed review of the literature revealed minimal direct cause and effect information related specifically to Mobility Teams. An article by Markey and Brown described an interdisciplinary approach to the development and implementation of activity and mobility guidelines.6 The article also describes common activity language, which led to a reduction in complications commonly associated with immobility in a medical-surgical patient population. Another study focused on having all patients assessed for functional status as soon as they were admitted, and making sure all patients had activity-level orders within 24 hours of admission.3 If the physician did not order bed rest, the goal was to have the patients up in a chair a minimum of once a day and to ambulate them if they were able.3 There were no studies in the literature review that demonstrated progressing activity orders to promote mobility based on nursing assessment of the patient’s functional ability using an algorithm. The importance of early mobilization for hospitalized patients was evident in the literature review.
The literature does support preventing complications from immobility, which can facilitate a decreased length of stay and, thus, create a financial benefit to the hospital. Prolonged bed rest has been associated with a number of well-documented adverse outcomes that can have severe consequences, especially for the elderly. Immobility is a well-recognized risk factor for a variety of adverse outcomes such as DVT, decubiti, and pulmonary insufficiency.7 Timmerman states that complete bed rest orders for prolonged periods should be a rare exception and should be questioned if a legitimate reason is not apparent.7 When bed rest is truly warranted, the rationale should be documented in the medical record at least once per shift. Kress also hypothesized that early mobilization of critically ill patients may offer benefit.2 Brower further described the consequences of bed rest and detailed several of the adverse effects.8 Rest is important for humans to allow healing and natural repair. However, the normally functioning human is physically active for substantial portions of each day, and physical activity has beneficial effects on many aspects of organ and system function.8
There were also added benefits to using lift teams to assist with mobilization of patients. Kutash et al discussed the development of a lift team at Tampa General Hospital and described the benefits to both patients and staff.9
PROGRAM INITIATIVES (PROCESS)
Shewhart’s Plan, Do, Check, Act (PDCA) rapid cycle improvement model was used to identify and develop our initiatives.10 Many patients, we noted, did not have an appropriate activity order within 24 hours of admission. Based on the team’s initial audits, the original plan was to develop an activity order set from which physicians could select an appropriate activity level based on the patient’s functional ability. The order set included five activity orders arranged from most restrictive to least restrictive, ie, bed rest, turn every 2 hours; dangle at bedside; up to chair—which included using the bedside commode; ambulate in room—which included bathroom privileges; and ambulate in hall. Avoiding “Up Ad Lib” and “As Tolerated” was the purpose of the order set. These terms were abstract and nondirective to the nursing staff, which caused limited advancement of activity level. In addition, the team encouraged staff to have every patient up in a chair for each meal unless medically contraindicated.
The team developed a mobility assessment form to allow nursing documentation to compare the current activity order to the patient’s functional level. The nurse was to notify the MD to request the activity level that matched the patient’s functional ability. Standardization of the daily functional mobility assessment was incorporated into the electronic medical record (EMR).
A “Get Moving Campaign” was initiated to focus efforts on mobilization of our patients within both the community and the hospital. To promote community awareness, our physician champion was featured on a local television programming segment, Healthy Lifestyles TV, declaring the benefits of early mobilization. Posters and buttons were used to kick off the campaign within the hospital.
Our Lift Team became an integral part of our mobility initiative. The Lift Team consists of specially trained team members from the patient transport department. Their initial training was completed by Physical Therapy. Education included proper body mechanics, safe patient handling, and competent lift equipment usage. In order to increase awareness of this service, a hospital-wide process to access the Lift Team was developed.
To facilitate the desired change throughout the entire organization, the following activities were undertaken:
- The physician champion created an educational video encouraging in-bed mobility for patients, including the use of an over-bed trapeze to promote self-mobility.
- Chart audits were completed to check for activity orders to assess the use of bed rest orders.
- A 24-hour bed rest alert was created and implemented within the EMR. The alert notifies a nurse if a patient has a bed rest order for greater than 24 hours. This alert prompts the nurse to consult with the physician to advance the patient’s activity if appropriate.
The development of the mobility algorithm (see Figure 2) was key to enhancing nurses’ autonomy by allowing nurse-driven activity orders. In tandem with the daily nursing mobility assessment, the algorithm empowered nurses to keep patients moving at the appropriate functional level. Physical therapy collaborated with nursing to develop the algorithm and policy based on the initial mobility order set.
- Physicians supported nursing’s autonomy to progress patients based on functional assessments. In keeping with physicians’ recommendations, the mobility committee developed a mobility algorithm, structured essentially as a decision-making tree utilized by members of the nursing staff for the mobility of their patients. To support the algorithm, a new mobility policy was also drafted and approved by the medical staff. Both documents were posted on the hospital’s intranet. An online educational lesson was developed and made available through e-learning for all clinical staff, explaining the mobility algorithm and new policy. Roving educational sessions were conducted by the Education Governing Group to each nursing unit during our monthly shared governance day.
- Revision of the nursing admission assessment included a functional assessment, which would trigger earlier therapy consults. This addition allowed therapy to evaluate and make recommendations early in a patient stay. Therapy could be instituted based on a patient’s functional level and needs.
Baseline audits were conducted in February 2009 to assess the percent of patients who received an activity order within the first 24 hours of admission. A random review of 25 inpatients revealed only 56% (14) of the patients audited had an activity order documented within the expected time frame. In July 2009, 270 patient charts were audited to assess the type of activity orders. This audit uncovered the following: 17.4% (47) bed rest, 28.5% (77) no orders, 21.9% (59) activities as tolerated, and other orders 32.2% (87).
Two main metrics were identified to best assess the Mobility Team’s objectives: 1) percent of patients with an activity order written within 24 hours of admission, and 2) percent of patients with an activity order appropriate for their condition on the day of the audit. Data collection plan included a random selection of three patients from each inpatient unit with a total sample size of 36 patients. Auditors were instructed to review the patient’s record for admission activity orders written within 24 hours of admission, and observe the patient’s functional level to assess the appropriateness of the current activity order. Quarterly audits were conducted to monitor the effectiveness of the Mobility Team’s actions to increase timeliness and appropriateness of activity orders. A 64.3% increase was noted in obtaining activity orders within 24 hours of admission from February 2009 to October 2010. Timeliness of admission activity orders has consistently reached greater than 90% over the last three quarters of 2010. Appropriateness of order for patient’s condition has continually reached greater than 90% for the last three quarters in 2010.
Metrics identified were therapy consults on day of discharge and number of mobility assists. These metrics were tracked by the Mobility Team. A change in these two fundamental processes added to the success in achieving timeliness and appropriateness of activity orders.
- A 24.4% decrease in therapy consults on day of discharge was realized when comparing August 2009 to August 2010 after the team implemented process changes to expedite consults earlier in the patient’s stay.
- Average monthly Lift Team utilization increased 11.03% from August 2009 to September 2010.
Other metrics tracked by the Mobility Team included length of stay and venous thromboembolism (VTE).
- Length of stay decreased from 5.1 days (February 2009) to 4.4 days (October 2010) representing a 13.7% decrease.
- Postoperative VTE rate (based on the AHRQ Patient Safety Indicators) declined by 31.8% from 1st Quarter 2009 to 3rd Quarter 2010.
Based on the actions of EJGH’s Mobility Team, the following have been achieved:
- Safe, early mobilization
- Decreased length of stay
- Decreased VTE
These accomplishments were made possible through process improvements such as:
- Earlier therapy orders
- Increased lift team usage
- Nursing autonomy regarding mobility initiation and progression
- Implementation of the mobility algorithm
The authors would like to acknowledge that other organizational efforts were addressing VTE rates at the same time of the mobility initiative. However, increasing patient mobility could only be viewed as supporting all other efforts.
Todd S. Danos, MBA, LOTR, is director of Therapy Services, East Jefferson General Hospital, Metairie, La; Sharon Pattison, LOTR, is supervisor of Inpatient Therapy Services; Joe Eppling, RN, MN, NEA-BC, CRRN, is assistant vice president, Acute Care, Post Acute, and Behavioral Health; Donna M. Carbajal, RN, RRT, MBA, is supervisor, Organizational Effectiveness; Donna Block, RN, BSN, is director of Step-down ICU Telemetry, Observation Unit, and IV Team; and Teri D’Gerolamo, RN, is supervisor of Step-down ICU Telemetry, Observation Unit, and IV Team. For more information contact
- Korupolu R, Gifford JM, Needham DM. Early mobilization of critically ill patients: reducing neuromuscular complications after intensive care. Contemporary Critical Care. 2009;6(9):1-12.
- Kress JP. Clinical trials of early mobilization of critically ill patients. Crit Care Med. 2009;37(10 Suppl):S442-S447.
- Critical Path Network. Six Sigma project slashes LOS for SNF discharges. Hosp Case Manag. 2007;15(11):167-169.
- Needham DM. Mobilizing patients in the intensive care unit: improving neuromuscular weakness and physical function. JAMA. 2008;300:1685-1690.
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- Markey DW, Brown RJ. An interdisciplinary approach to addressing patient activity and mobility in the medical-surgical patient. J Nurs Care Qual. 2002;16:1-12.
- Timmerman RA. A mobility protocol for critically ill adults. Dimens Crit Care Nurs. 2007;26:175-179.
- Brower RG. Consequences of bed rest. Crit Care Med. 2009;37(10 Suppl):S422-S428.
- Kutash M, Short M, Shea J, Martinez M. The lift team’s importance to a successful safe patient handling program. Journal of Nursing Administration. 2009;39(4):170-175.
- Brown P, Hare D. Rapid cycle improvement: controlling change. The Journal of the Arkansas Foundation for Medical Care. 2002;98(10):2-3.