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); 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.

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 >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.

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 (>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.

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 2011,24:195–201.

8. Benefits of early ambulation

9. Early Ambulation in medicine patients decreases LOS • 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.

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; 124:883–889.

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 >/= 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.

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; P<0.001)

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

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 < 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. No difference in falls Source: Titsworth WL, et. al. The effect of increased mobility and morbidity in the neurointensive care unit. J Neurosurg 116:1379–1388, 2012.

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- 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)

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); 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.

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 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.