key: cord-1002825-e6e49og0
authors: Bergbower, Emily Anne Smith; Herbst, Cole; Cheng, Nan; Aversano, Alexander; Pasqualini, Katherine; Hartline, Cierra; Hamby-Finkelstein, Devorah; Brewer, Colin; Benko, Stephen; Fuscaldo, Joseph
title: A novel early mobility bundle improves length of stay and rates of readmission among hospitalized general medicine patients
date: 2020-09-03
journal: Journal of community hospital internal medicine perspectives
DOI: 10.1080/20009666.2020.1801373
sha: 926c7877caf6d6d595afc21bc46409a7b59165c3
doc_id: 1002825
cord_uid: e6e49og0

Inpatient early mobility initiatives are effective therapeutic interventions for improving patient outcomes and decreasing use of hospital resources among adult ICU and general medicine patients. To establish and demonstrate guidelines for early patient ambulation, we developed and implemented a novel multidisciplinary mobility bundle utilizing the JH-HLM (Johns Hopkins Highest Level of Mobility) scale for mobility classification, on a single adult general medicine unit of a community hospital. Our results show that patients admitted to the unit after implementation of the mobility bundle had improved mobility scores, reduced rates of 30-day hospital readmission, and a shortened length of hospital stay. This study emphasizes the importance of measuring mobility using a systematic method, easing workflow among unit practitioners, and allowing mobility initiatives to be jointly driven by nursing, physical therapy, and physicians.

Hospitalization for acute illness is associated with a decline in functional status, even when patients fully recover [1] [2] [3] [4] . This decline in functional status is multifactorial in origin and has been attributed to poor pain management, improper nutrition, sleep disturbances, and as an effect of the illness which precipitated the admission [2, [4] [5] [6] [7] [8] . In particular, prolonged immobilization and subsequent deconditioning is a very common cause of functional decline during hospitalization and many studies have demonstrated that hospitalized patients are mobilized infrequently and spend most of their time in bed [9] [10] [11] [12] [13] . As such, these patients are vulnerable to a host of hospitalization-related complications including the inability to preform activities of daily living, increased length of stay (LOS), frequent readmissions, and the need for discharge to rehabilitation facilities [2, [14] [15] [16] [17] [18] . There are medical consequences as well, which include, but are not limited to, thromboembolism, muscle weakness, joint contractures, urinary incontinence, and skin breakdown [19, 20] .

Early mobilization has been demonstrated to be an effective therapeutic intervention for improving outcomes among both ICU and general medicine adult patients [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] . Prior studies consistently demonstrate decreased use of hospital resources as well as improvement in length of hospital stay, especially among patients with myocardial infarctions, total knee replacements, hip fractures, and community acquired pneumonia [24, [32] [33] [34] [35] [36] [37] [38] [39] . In 2013, Engel et al. demonstrated significant improvements in both physical and neurocognitive outcomes among ICU survivors who were subjected to early mobility and rehabilitation [40] . Furthermore, early mobility programs may even reduce the incidence of hospital acquired pneumonia in patients with hip fractures [41] . However, despite this data, there are currently no established consensus for guidelines or therapeutic protocols regarding early mobilization during hospitalization for adult patients in the ICU or on general medicine units.

Here, in an effort to establish and demonstrate guidelines at our institution for early patient ambulation, we developed a novel mobility bundle and investigated its effects on patient length of stay, 30day readmissions, and discharge destination. The purpose of this study was not only to improve patient outcomes and reduce hospital resources, but also to evaluate the feasibility of implementing a unit wide mobility protocol as well as its effects on the ease of workflow among various groups of unit practitioners. Here, we present one of the first comparative analyses of patient populations before and after implementation of an early mobility protocol that is jointly driven by nursing, physical therapy, and physicians.

The QI project setting was a single 26 bed general medicine unit at the Greater Baltimore Medical Center (GBMC), a community hospital in Towson, Maryland. We used the established JH-HLM (the Johns Hopkins Highest Level of Mobility) scale to document patient mobility milestones [37] . The six point mobility bundle included door signs for each room listing the JH-HLM chart and goals, and required JH-HLM documentation by nursing at admission and discharge with discussion of the assigned JH-HLM score at the daily multidisciplinary huddle. Each day, set up of the reclining chairs in every patient room was required prior to the morning change of shift. We established a daily unit metric for tracking chair set up with a goal of at least 80%. Additionally, we implemented a unit rule to have all patients out of bed by 2:00 PM each day with tracking. Finally, physician and nursing staff education regarding early mobility and the JH-HLM scale was conducted.

The planning phase of the QI project occurred in the early winter of 2019. This project was reported to the institutional review board (IRB) committee at GBMC for approval. It was deemed to meet the requirements of a QI research project, for which IRB oversight is not necessary. A pre-mobility bundle implementation phase of data collection to assess the unit's baseline occurred throughout the month of January 2020. This was followed by an education phase from 1 February 2020 to 15 March 2020. During the education phase, we involved key stakeholders (nurses, certified nursing assistants, physical therapists, administrators, and physicians) in the QI project team and worked to streamline implementation of the mobility bundle and identify barriers to improvement. A second phase of data collection occurred after the education phase from 16 March 2020 to 15 April 2020. Patient cases were excluded from assessment of daily mobility if they were noted to be hemodynamically unstable (HR >110 with BP <90/50), off the unit for surgery or extended testing for more than 4 h, or severely agitated requiring administration of restraints and/or antipsychotic medications. Exclusion on aparticular day did not prevent the patient from being assessed on the other days of their admission, particularly those patients that were excluded on aspecific day for surgery or extended testing.

Information extracted from patient charts includes patient demographics (age, weight, gender), documented JH-HLM scores, hospital length of stay (LOS), the occurrence of a readmission within 30 days of a patient's discharge date, falls, and inpatient physical therapy (PT) recommendations. The primary outcome was the occurrence of the mobility bundle as an intervention, allowing us to compare data from the pre-bundle implementation phase to the post-bundle implementation phase. Secondary outcomes include JH-HLM score improvement and hospital LOS.

In the bivariate analysis, categorical data were compared using the Fisher's exact test and Pearson's Chi-squared test. Non-categorical data were compared using the Mann-Whitney U test. Linear and logistic regression were used to examine the association of outcomes with patient, clinical, and mobility characteristics. P-values <0.05 were considered statistically significant. All tests were two sided. Statistical analyses were performed with GraphPad Prism 8.

During the QI project period, a total of 340 patients were admitted and subsequently included in the analysis. One hundred and seventy-seven patients were admitted in the pre-bundle phase, and 163 in the post-bundle implementation phase. Overall, the mean daily percent of patients out of bed increased from 64.9% to 78.6% when comparing the pre and post phases. Baseline patient characteristics are summarized in Table 1 .

After a 1-month period of observation to assess the unit's mobility baseline, a 6-week education phase occurred to allow for thorough and effective implementation of our novel mobility bundle. The six point bundle focuses on changing the behaviors of key unit stakeholders to improve daily patient mobility. This includes required JH-HLM documentation by nursing, door signs on every patient room listing the JH-HLM chart, daily chair set up prior to the morning change of shift, a daily unit LDM metric requiring chair set up of at least 80%, a unit rule to have all patients out of bed by 2:00PM each day, and physician/nursing education regarding early mobility and the JH-HLM scale.

Bivariate analysis ( Table 2) showed that the mobility bundle was associated with increased odds of JH-HLM score improvement, which occurred in 31.3% of patients assessed after bundle implementation compared with 21.5% of those assessed prior (OR 1.67; 95% CI 1.02-2.69; P = 0.048). Additionally, the mobility bundle was associated with a decreased risk of hospital readmission within 30 days of discharge, dropping from 22% to 10.4% after mobility bundle implementation (OR 0.41; 95% CI 0.23-0.75; P = 0.005). Among noncategorical variables, a shortened length of hospital stay (mean time 5.8 days vs. 4.8 days; P = 0.013) was associated with implementation of the mobility bundle (Table 3 ). Our noted improvements in mobility were not associated with a statistically significant increased rate of injurious falls. Our patient populations pre and post intervention were matched in age, weight, and gender. Additionally, the number of PT/OT inpatient assessments were equivalent between the two groups (47.5% vs. 50.3%). Table 4 presents the independent variables that are predictive of the mobility bundle when evaluated by multivariable logistic regression analysis. Similar to the bivariate analysis, JH-HLM score improvement (OR 1.19; 95% CI 1.11-3.30; P = 0.021) was independently associated with implementation of the mobility bundle. Length of hospital stay (OR 0.94; 95% CI 0.89-0.99; P = 0.028), 30-day readmission (OR 0.39; 95% CI 0.20-0.73; P = 0.0042), and the need for home physical therapy at discharge (OR 0.28; 95% CI 0.09-0.78; P = 0.017) were inversely associated with implementation of the mobility bundle. Table 4 also presents the independent variables that are predictive of JH-HLM score improvement as a secondary outcome. Both mobility bundle implementation (OR 1.94; 95% CI 1.12-3.39; P = 0.019) and inpatient PT/OT (OR 2.75; 95% CI 0.98-7.32; P = 0.046) were independently associated with JH-HLM score improvement. Age, gender, weight, discharge to a rehabilitation facility, 30-day readmission, and the need for outpatient PT/OT were not statistically significant predictors. Table 5 presents the independent variables that are predictive of length of hospital stay (days) as a secondary outcome. In a multivariable linear regression analysis, mobility bundle implementation (Estimate −1.22; P = 0.022) was inversely associated with length of hospital stay, and discharge to a rehabilitation facility (estimate 3.56; P = 0.0014) was positively associated with length of hospital stay. Age, weight, gender, JH-HLM score improvement, 30-day readmission, and the need for outpatient PT/OT were not statistically significant predictors.

Inpatient mobility initiatives in their various forms are effective interventions for decreasing length of hospital stay, lessening morbidity, and improving both strength and physical function [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] . However, many of these initiatives are limited in scope or address the actions of only one specific group of unit practitioners. Here, in an effort to improve patient outcomes, we conducted a QI project on one general medicine unit at a community hospital, and implemented a novel mobility bundle which engages several groups of key unit stakeholders. We then compared clinical and mobility related characteristics between patients admitted during the pre and post intervention periods to assess for factors associated with implementation of the bundle and improvements in mobility overall.

Our findings indicate that early mobilization through a standardized protocol has a significant impact on patient outcomes, especially length of stay, individual patient mobility, and 30-day readmissions, as well as the use of hospital resources. This is in keeping with the findings of Pashikanti et al.

(2012) who conclude that well defined early mobility protocols provide the greatest impact [22] . However, patient benefits have been noted from very different types of mobility initiatives. Some beneficial interventions have focused on electronic health record tools, carefully assessing clinical issues precluding mobility, the availability of equipment, step tracking, and the designation of mobility representatives [24, 26, [41] [42] [43] . While many variations of early mobility initiatives have been successful in the short term, we posit that our modifications and novel bundle could be more successful long term due to its multidisciplinary approach.

One of the major barriers discussed in the planning phase of this project was the additional burden of work that mobility initiatives often place solely on nursing. This has been acknowledged in prior studies as an existing barrier that is often a concern for multiple groups of unit stakeholders, including physical therapy [44, 45] . However, many existent studies are still solely nursing driven [21, 37, [46] [47] [48] . Our intervention established a multidisciplinary focus of incorporating nurses, certified nursing assistants (CNAs), physicians, and physical therapists to ease workflow and relieve this burden. First, we mobilized certified nursing assistants and resident physicians to assist with encouraging or physically maneuvering patients to get out of bed by 2PM each day, in addition to the daily efforts of physical therapy. Second, it was noted in the planning phase of this project that chair set up was left entirely to nursing and often couldn't be accomplished until late afternoon, if at all, due to the volume of tasks and meetings set in the first six to eight hours of the scheduled shift. We re- delegated the task of chair set up to CNAs assigned to the night shift, and required at least 80% of chairs to be set up for patient use by the 7AM change of shift. A unit LDM metric was established to record chair set up and it was presented daily to executive management as part of the LDM curricula for the hospital. As such, we were not only able to effectively implement required chair set up, but we also made the process of getting patients into the chair less cumbersome for the day shift nurses during their medication rounds. Of additional note is the issue of standardized quantification of mobility. A systematic method for assessing a patient's functional status can provide key data on tailoring mobility goals for an individual patient and identifying who is appropriate for mobilization. It also provides a mechanism for all groups of unit stakeholders to consider mobility in the same language and predict outcomes with regards to discharge disposition [49, 50] . There are multiple systematic methods for assessing functional status, including the Activity Measure for Post-Acute Care (AM-PAC) Inpatient Mobility Short Form (IMSF), the JH-HLM Scale, and the de Morton Mobility Index (DEMMI), among others. Each has been demonstrated as a useful and predictive measurement of mobility [37, [50] [51] [52] [53] [54] [55] . However, the vast majority of the inpatient early mobility initiatives cited in this paper do not incorporate any systematic quantification method. While we relied on the JH-HLM scale, which we found easy to use and to incorporate into our practice, we posit that some form of systematic method can and should be utilized in all early mobility initiatives to provide not only a common platform of language between various groups of hospital practitioners but also to accurately track individual patient mobility improvements or declines.

This study is limited in several regards. First, this is a single site study focused on a single medical/ surgical unit with a small sample size. Further research is needed to establish if this mobility bundle can be implemented successfully on a larger scale across multiple units. Second, this study occurs over a very limited frame. Future studies should focus on a longer course of assessment and data collection to determine if these improvements are reproducible over an extended period of time. Third, although patient characteristics are very similar between the two periods, we cannot rule out the possibility that various established LDM metrics as well as broader QI efforts at our institution contributed to this reduction in length of stay and 30-day readmissions. Fourth, this study occurred during the beginning of a national outbreak of COVID-19. While our general medicine unit was not a designated COVID-19 unit, it is unclear if the hospitalized patient population was affected by the pandemic. Lastly, while nursing and physical therapy consistently documented JH-HLM scores throughout the admission, this method of scoring mobility does not effectively address other critical factors such as the frequency with which patients were mobilized or the length of time patients engaged in a specific activity. Thus, while the JH-HLM score is a straightforward way to measure mobility, it cannot fully represent the activity of our patients in totem.

In conclusion, we developed and implemented a novel early mobility bundle with a distinct multidisciplinary approach that established and demonstrated guidelines for early patient ambulation in our hospital. Our results show that we improved patient outcomes regarding mobility, length of hospital stay, and 30-day readmissions while subsequently reducing hospital resources. Additionally, creating a mobility protocol jointly driven by nursing, physical therapy, and physicians eased workflow among the staff, made implementation of the protocol feasible, and actively addressed barriers to mobility that could have prevented a productive inpatient initiative.

Author contributions E.A.S. Bergbower, J. Fuscaldo, and S. Benko designed the novel mobility bundle. Additionally, E.A.S. Bergbower collected data, designed the statistical analysis, interpreted data, and wrote the manuscript. C. Herbst was instrumental in data retrieval and analysis. A. Aversano and N. Cheng preformed physician and nursing education initiatives. K. Pasqualini, C. Hartline, C. Brewer, and D. Hamby enforced implementation of the mobility bundle and assisted with data collection. 

No potential conflict of interest was reported by the authors.

She was probably able to ambulate, but I'm not sure

Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age

Effects of functional status changes before and during hospitalization on nursing home admission of older adults

Prevalence and outcomes of low mobility in hospitalized older patients

Comparison of functional outcomes associated with hospital at home care and traditional acute hospital care

Post-hospital syndrome-an acquired, transient condition of generalized risk

Mobility limitation in the older patient: a clinical review

The natural history of functional morbidity in hospitalized older patients

Frequency of hallway ambulation by hospitalized older adults on medical units of an academic hospital

The sedentary behaviour and physical activity patterns of survivors of a critical illness over their acute hospitalisation: an observational study

Geriatric hospital medicine

The underrecognized epidemic of low mobility during hospitalization of older adults

Frequency and duration of nursing care related to older patient mobility

Time to ambulation after hip fracture surgery: relation to hospitalization outcomes

Physical fitness and all-cause mortality. A prospective study of healthy men and women

Mobilizing patients in the intensive care unit: improving neuromuscular weakness and physical function

Rehabilitation quality improvement in an intensive care unit setting: implementation of a quality improvement model

Association of impaired functional status at hospital discharge and subsequent rehospitalization

Consequences of bed rest

Association of urinary incontinence with impaired functional status among older people living in a long-term care setting

Sustainability of a nurse-driven early progressive mobility protocol and patient clinical and psychological health outcomes in a neurological intensive care unit

Impact of early mobilization protocol on the medical-surgical inpatient population: an integrated review of literature

Receiving early mobility during an intensive care unit admission is a predictor of improved outcomes in acute respiratory failure

Early ambulation and length of stay in older adults hospitalized for acute illness

The economic and clinical impact of an early mobility program in the trauma intensive care unit: a quality improvement project

Impact of an early mobilization protocol on outcomes in trauma patients admitted to the intensive care unit: A retrospective pre-post study

Mobility and functional status among hospitalized COPD patients

Physical therapy on the wards after early physical activity and mobility in the intensive care unit

Clinical review: early patient mobilization in the ICU

Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial

The effect of early mobilization in critically ill patients: A meta-analysis

Earlier physical therapy input is associated with a reduced length of hospital stay and reduced care needs on discharge in frail older inpatients: an observational study

Early mobilization of patients hospitalized with community-acquired pneumonia

Early inpatient rehabilitation after elective hip and knee arthroplasty

Early ambulation after myocardial infarction. The in-patient exercise program

The benefits of implementing an early mobility protocol in postoperative neurosurgical spine patients

Promoting mobility and reducing length of stay in hospitalized general medicine patients: A quality-improvement project

Integrating a standardized mobility program and safe patient handling

Effect of early mobility as a physiotherapy treatment for pneumonia: a systematic review and meta-analysis

ICU early mobilization: from recommendation to implementation at three medical centers

The early mobility bundle: a simple enhancement of therapy which may reduce incidence of hospital-acquired pneumonia and length of hospital stay

Electronic health record tool to promote team communication and early patient mobility in the intensive care unit

A mobility program for an inpatient acute care medical unit

Barriers to mobility during hospitalization from the perspectives of older patients and their nurses and physicians

Barriers to early mobility of hospitalized general medicine patients: survey development and results

Dose of early therapeutic mobility: does frequency or intensity matter?

Impact of a nurse-driven mobility protocol on functional decline in hospitalized older adults

Extra physical therapy reduces patient length of stay and improves functional outcomes and quality of life in people with acute or subacute conditions: a systematic review

Prediction of disposition within 48-hours of hospital admission using patient mobility scores

Toward a common language for measuring patient mobility in the hospital: reliability and construct validity of interprofessional mobility measures

Measuring mobility in low functioning hospital patients: an AM-PAC replenishment project

Measuring mobility in patients living in the community with Parkinson disease

Measuring mobility in older hospital patients with cognitive impairment using the de Morton mobility index

Using a real-time location system for assessment of patient ambulation in a hospital setting

Creating a culture of mobility: using real-time assessment to drive outcomes

The authors would like to thank the physical and occupational therapy staff of the Center for Rehabilitation Medicine at GBMC for their support and feedback during this process. The authors would also like to thank the entirety of the staff working on Unit 34 at GBMC for their assistance, support, and thoughtful patient care.

The authors have no funding sources to report.

Emily Anne Smith Bergbower http://orcid.org/0000-0002-7937-2661 Nan Cheng http://orcid.org/0000-0003-2858-1639