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Promoting Early

Mobility / Ambulation
in Medical Patients
Mayu Hoang, Julie Mayo, Kristin Schmitt,
Shana Vazquez, Susan Castillejos

Summary of the problem


Hospitalization or illness that necessitates time in bed, negative effects of
bedrest on the body can have a serious impact on health.
Effects of Immobility
Cardiovascular: SV, CO, Risks developing DVT and PE,
Respiratory: Oxygen uptake, Potential for atelectasis, Resp. failure
Muscles and bone: strength, bone loss, bone density
GI and GU: Malnutrition, anorexia, constipation, Incontinence
Skin: shearing force, skin breakdown
Medical patient which include ICU, trauma, Med/surg, elderly patients lead
to longer Hospital stay and higher cost to the hospital

Physiological changes during bedrest


The Processes of the issue
Day 1
Contractures
begin
Skeletal
muscle
atrophy
Pressure

Day 2
Loss of
muscle
strength,
blood flow

Early ambulation promotes


-Shorter hospital stay
-Decrease cost

Day 3 Plasma
Volume
CV workload
(HR, SV,
CO)
orthostatic
hypotension

Day 5
microvascular
dysfunctions

By Day 8
Bone degradation
begins and
continues as long
as bed rest occurs

Day 7
Visible weakness
Ca+ in urine
10% in postural
muscle strength

The Numbers Behind the Impact of Bedrest vs. Early


Ambulation/Mobility on Patient & Hospital Outcomes
Negative Patient Outcomes:
Respiratory
Failure

Deep Vein
Thrombosis/
Pulmonary
Embolism

The Problem in the Hospital:

2011 National
2011 National
Example in Numbers
Patient Safety
Patient Safety
> Population Aged > 65yr in U.S. = 12.5% or 35 million
Indicator:
> 45 medical patients
> 65yr able to walk in 2Indicator:
weeks prior to hospitalization
> Wireless accelerometers attached to patient thigh for first 7 days
hospitalization
> Mean length of stay: 5.1 days
> Generated: 2,592 hours data
> 35 patients or 77.8%
were
willing
and able to
walk aper
short
distance
10.74
per
1,000
8.14
1,000
independently
> 83% of measured hospital stay was spent lying in bed
> Median time any one patient spent standing or walking a day:
43 minutes
(Brown, 2009)

Evidenced Based Practice: Research in Support


> Study that Shows No Adverse Outcomes Associated with Early Ambulation/Mobility in the Hospital Setting:
Study #1
Journal: Critical Care Medicine
Study: Early activity is feasible and safe in respiratory failure patients performed in 2003
Participants: ICU Patients on mechanical ventilation > 4 days.
Measure: six activity-related adverse events: fall to knees, tube removal, systolic blood pressure >200 mm Hg, systolic blood pressure <90 mm Hg, oxygen
desaturation <80%, and extubation after ambulation or activity events: sitting up in bed, to chair, ambulate in hall
Results: a total of 1,449 activity events in 103 patients. The activity events included 233 (16%) sit on bed, 454 (31%) sit in chair, and 762 (53%) ambulate,
there were <1% activity-related adverse events (Bailey, 2007).

> Study that Shows Positive Outcomes Related to Early Ambulation/Mobility in the Hospital Setting :
Study #2
Journal: Chest (American College of Chest Physicians)
Study: Early mobilization of patients hospitalized with community-acquired pneumonia performed in 1997-1998
Participants: General Medical Patients with CAP
Measure: Early Mobility (EM) was defined as sitting or ambulating out of bed for >20 min in first 24 hours of admission
Results: Hospital length of stay for EM vs usual care was 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 between treatment groups (Mundy, 2003).

QI Tools

Progressive Mobility Continuum


Direct Observation Pre & Post Implementation Data
Collection Tool

Assess & record patient mobility levels

Observe & record interventions & compare

Recommendations
-Initiate mobility within 24 hours after
admission
-Initiate PT and OT therapy along with ROM
-Educate nurses and staff about Early
Mobility Program

Early Mobility Program


-Engage interdisciplinary team to devise plan
for early mobility and walking program
-Evaluate patient for phase to determine
level of care
-Create a Standard of Care

Evaluating the Success: What data will be monitored?

Daily assessments of pts mobility to evaluate for any


changes
Record all activity (type of activity and duration of activity),
how the pt tolerated the activity and adverse effects, if any
Determine days time to first OT/ PT consult, days to sitting
up in bed, out of bed to chair, standing, and ambulation
Patient outcomes:

Post discharge complications and early


readmissions

Admission to rehab facilities


Comparing numbers: Some organizations may select to use
structural, process, outcome, and patient experience
measures. Nationally recognized and standardized
measures that have already been developed and tested
should be used whenever possible. Examples of general
sources of clinical measures include:

Healthy People 20/20

National Quality Forum

AHRQ Clearinghouse of Clinical Measures

References
Bailey, P., Thomsen, G., Spuhler, V., Blair, R., Jewkes, J., Bezdjian, L., ... Hopkins, R. (2007). Early activity is feasible and safe in respiratory failure patients.
Critical Care Medicine, 35(1), 139-145. Retrieved February 20, 2015, from http://www.ncbi.nlm.nih.gov/pubmed/17133183
Basses, R., Vollman, K., Brandwene, L., Murray, M. (2011). Integrating a multidisciplinary mobility programme into intensive care practice (IMMPTP): A
multicentre collaborative. Intensive and Critical Care Nursing, 28 (2), 88-97. Retrieved February 22, 2015, from
http://www.sciencedirect.com.ezproxy.library.kapiolani.hawaii.edu:8080/science/article/pii/S0964339711001303?np=y
Developing and Implementing a QI Plan. (n.d.). Retrieved February 22, 2015, from
http://www.hrsa.gov/quality/toolbox/methodology/developingandimplementingaqiplan/part4.html
Brahmbhatt, N., Murugan, R., & Milbrandt, E. (2010). Early Mobilization Improves Functional Outcomes In Critically Ill Patients. Critical Care, 321-321.
Brown, C., Redden, D., Flood, K., & Allman, R. (2009). The underrecognized epidemic of low mobility during hospitalization of older adults. Journal of the
American Geriatrics Society, 57(9), 1660-1665. Retrieved February 21, 2015, from http://www.ncbi.nlm.nih.gov/pubmed/19682121
Engel, H., Needham, D., Morris, P., & Gropper, M. (2013). ICU Early Mobilization.Critical Care Medicine, S69-S80.
Fact Sheet on Inpatient Quality Indicators. (2013). Retrieved February 21, 2015, from
http://www.ahrq.gov/professionals/systems/hospital/qitoolkit/complete_qitoolkit.pdf
Gallagher, S., Kumpar, D., Harrington, S., Wilson, K., & Zock, R. (n.d.). Advancing the Science and Technology of Progressive Mobility. Retrieved February
22, 2015, from
http://www.nursingworld.org/MainMenuCategories/WorkplaceSafety/Healthy-Work-Environment/SafePatient/Advancing-the-Science-and-Technology-of-Progre
ssive-Mobility.PDF
King, L. (2012). Developing a progressive Mobility Activity protocol. Orthopaedic Nursing, October 2012, Volume 31, 253-262.
Mundy, L. (2003). Early Mobilization Of Patients Hospitalized With Community-Acquired Pneumonia. Chest, 124(3), 883-889. Retrieved February 21, 2015,
from http://www.ncbi.nlm.nih.gov/pubmed/12970012
Perme, C., & Chandrashekar, R. (2009). Early Mobility And Walking Program For Patients In Intensive Care Units: Creating A Standard Of Care. American
Journal of Critical Care, 18, 212-221.