Early Ambulation in Medicine Patients

1
Early Ambulation in Medicine Patients

• Sheila Modi
• Hospitalist Best Practice Meeting
• September 19, 2012

2
Objectives

• 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

3
Bed rest causes harm
4
Bed Rest is Harmful

• 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) 2008251Y265.
• Truong, AD, et al. Bench-to-bedside review
  Mobilizing patients in the intensive care unit
  from pathophysiology to clinical trials. Critical
  Care 2009 , 13216.

5
Functional decline during hospitalization

• 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 gtage 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/cd 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) 2008251Y265.

6
Functional decline does not improve

• Older people who develop new functional deficits
  during hospitalization are less likely to recover
  lost function.
• One study 1279 older adults (gt70yrs)
  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. 1996156(6)645652.

7
Delirium

• 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 2011,24195201.
8
Benefits of early ambulation
9
Early Ambulation in medicine patients decreases
LOS

• Study of 162 pts, age gt/ 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 gt/ 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) 19421943.
10
Early Mobilization in CAP decreases LOS

• 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 124883889.
11
Early Mobilization in CAP decreases LOS

• 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.

12
Mobility protocol for medicine patients
maintains/improves functional status and
decreases LOS

• Study with n 50 pts, adults gt/ 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-Dec24(4)325-31.
13
Mobility protocol for medicine patients
maintains/improves functional status and
decreases LOS

• 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 Plt0.001)

14
Early mobility decreases complications in DVT/PE

• Compression and walking versus bed rest in the
  treatment of proximal deep venous thrombosis with
  low molecular weight heparin

• 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.

• Immediate mobilization in acute vein thrombosis
  reduces post-thrombotic syndrome

• 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. 200032861Y869.
• Partsch H, et al. Immediate mobilization in acute
  vein thrombosis reduces post-thrombotic syndrome.
  Int Angiol. 200423(3)206Y213.

15
Early post-op ambulation in surgical patients
decreases post-op complications

• 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

A 37 decrease in paralytic ileus represents
potential annual cost savings of 830,000
Note no increase in falls
Source Kibler VA, et. al. Early Postoperative
Ambulation Back to Basics. AJN. April 2012
112(4) 63-69.
16
Increased mobility in NSI decreases LOS and
hospital complications

• 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 lt 0.0001).
• Reduction in neurointensive care unit length of
  stay (LOS p lt 0.004), hospital LOS (p lt 0.004),
  hospital-acquired infections (p lt 0.05), and
  ventilator-associated pneumonias (p lt 0.001), and
  decreased the number of patient days in
  restraints (p lt 0.05).
• Additionally, increased mobility did not lead to
  increases in adverse events as measured by falls
  or inadvertent line disconnections.

No difference in falls
Source Titsworth WL, et. al. The effect of
increased mobility and morbidity in the
neurointensive care unit. J Neurosurg
11613791388, 2012.
17
(No Transcript)
18
SUMMARY
19
Early Ambulation Benefits

• 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).

20
Perceived Problems at UNM

• 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?

21
Snapshot from 8/31/2012

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

22
MOVING FORWARD
23
Step 1 Work more effectively with what we have
now

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

24
Step 2 Work towards increasing mobility in all
of our patients

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

25
Step 2 Work towards increasing mobility in all
of our patients

• 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- dont write bed rest
• D/c Foley
• Judicious use of telemetry (we lack wireless
  telemetry)
• Dont keep isolation patients in their rooms
  (they can walk with gowns)

26
Resources

• 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) 2008251Y265.
• Truong, AD, et al. Bench-to-bedside review
  Mobilizing patients in the intensive care unit
  from pathophysiology to clinical trials. Critical
  Care 2009 , 13216.
• 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
  2011,24195201.
• Mundy, LM, et al. Early Mobilization of Patients
  Hospitalized With Community-Acquired Pneumonia.
  CHEST 2003 124883889.
• 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 11137(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. 200032861Y869.
• Partsch H, et al. Immediate mobilization in acute
  vein thrombosis reduces post-thrombotic syndrome.
  Int Angiol. 200423(3)206Y213.
• Sager MA, Franke T, Inouye SK, et al. Functional
  outcomes of acute medical illness and
  hospitalization in older persons. Arch Intern
  Med. 1996156(6)645652.
• 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) 19421943.
• Padula CA, et. al. Impact of a nurse-driven
  mobility protocol on functional decline in
  hospitalized older adults. J Nurs Care Qual. 2009
  Oct-Dec24(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 11613791388, 2012.
• Pashikanti L, Von Ah D. Impact of Early
  Mobilization Protocol on the Medical-Surgical
  Inpatient Population. Clin Nurse Spec. 2012
  Mar-Apr26(2)87-94.

27
(No Transcript)
28
Early Mobility in DVT/PE

• 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 11137(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 p0.90). 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
  p0.21) and lower incidence of new PE and overall
  mortality (RR 0.79 95 CI 0.402-1.56 p0.50).
• 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.