Published in the November 2015 issue of Today’s Hospitalist
A GROUNDBREAKING STUDY on early mobility done at Johns Hopkins in 2008 was one of the first to challenge the idea that complete bedrest should be standard practice in the ICU. Published in the Oct. 8, 2008, issue of the Journal of the American Medical Association, the study found that even for ICU patients on ventilators, early ambulation was not only feasible but safe “and could deliver big benefits.
“That provided a really important framework,” says Erik Hoyer, MD, deputy director for patient safety in Johns Hopkins’ department of physical medicine and rehabilitation. “If you can mobilize your sickest patients, you can probably do it as well in the post-ICU setting.”
Dr. Hoyer’s own research has quantified how patients can benefit from getting out of bed and moving. One study published in the May 2014 Journal of Hospital Medicine, for instance, found that patients admitted from acute care to inpatient rehab with lower functional status had as much as a threefold greater risk of being readmitted. That type of evidence is giving the whole notion of early ambulation in hospitals much more traction.
“We’ve been able to link early mobility to initiatives the hospital really cares about.”
“A lot of it is timing, and we’ve been able to link early mobility to initiatives the hospital really cares about,” he points out. Those include not only reducing readmissions but also length of stay, and preventing falls and DVTs.
But getting buy-in is a long way from making early mobility a reality on the wards. To do so, Dr. Hoyer and his colleagues have had to take some initial steps to put a necessary framework in place.
“We don’t have any standardized ways to measure patient function in the hospital,” points out Dr. Hoyer, who’s part of a multidisciplinary Johns Hopkins team spearheading an initiative to promote activity and mobility. “There isn’t even a code to describe function, so we have to develop a language that multiple disciplines can use to get on the same page.”
Barriers to early mobility
As a first step, Dr. Hoyer and his team created and got approval for a functional status assessment at Johns Hopkins Hospital. That assessment, he explains, includes two scales.
The first, named the Johns Hopkins Highest Level of Mobility scale, “is an ordinal scale from 1 to 8, with numbers representing mobility milestones that patients accomplish, based on observation,” he says. Patients who score a 2 have some type of bed mobility, while those scoring an 8 can walk more than 250 feet.
The other tool they’ve adopted is the Activity Measure for Post-Acute Care (AM-PAC), which was developed by Boston University. “There’s a short-form version that physical and occupational therapists use to document patients’ level of impairment,” says Dr. Hoyer.
“By using the two tools concurrently, nurses and therapists for the first time can document functional status and impairment using the same measures.”
But even with such tools, Dr. Hoyer’s team ran into another major barrier to getting early mobility off the ground: the lack of nursing time. He and his colleagues surveyed both nurses and physical therapists at Johns Hopkins about early mobility efforts, publishing their results in the April 2015 issue of the American Journal of Physical Medicine & Rehabilitation.
The survey indicated that nurses perceive that they don’t have the time to mobilize patients. “They feel they have so many other tasks that mobility becomes less of a priority,” he says. “And a patient who needs a lot of help to be mobilized may require a lift and the help of two or three nurses. Within the context of an incredibly busy service, that can be very challenging.”
Who really needs PT or OT?
To tackle that dilemma, Dr. Hoyer and his colleagues partnered this year with neurology on two units that have between 25 and 30 patients each. Their first objective was to identify the right providers to mobilize patients.
It turns out that the right provider depends on patients’ functional status and the amount of help they need. “If patients are very independent,” he points out, “they may need only instructions on how to walk a few laps in the hall or to have family members ambulate with them.”
Patients who need a bit more assistance, by comparison, might require the help of a nurse or a tech on the floor. And patients who require a lot more effort, he adds, “might benefit from physical or occupational therapy, helping them ambulate or working as a consultant to create a mobility care plan.”
Dr. Hoyer and his team then looked at current practices within the neurology units in terms of physical and occupational therapy consults. They found that nurses on those units were already documenting patients’ AMPAC scores, which range from 6 through 24.
“A 24 means that patients have no impairment with any of the mobility items we ask of them, including going up and down stairs or walking about their room,” he explains. “But we found that a significant number of neurology patients with an AM-PAC score of 24 were still being evaluated by PT or OT, even though they had no need.”
That’s when the team devised a quality improvement project based on patients’ AM-PAC scores.
“If the nurse scores a patient as a 24 and that patient has a consult for PT or OT, we now bring this up with the team on the unit and perhaps cancel that consult,” Dr. Hoyer notes. Before the pilot program, about 14% of patients on the neurology units with an AM-PAC score of 24 were seen by physical or occupational therapists.
That percentage has since dropped to 6.6% without any increase in the number of patient falls. At the same time, “we increased the number of consults for patients with greater impairment,” he says. To make sure discussions about who needs therapy take place, team members on the neurology wards hold daily care coordination rounds. Nurses are also encouraged to contact residents if they think therapy isn’t needed for certain patients.
“We’ve also given therapists the autonomy to question whether a specific patient really needs to be seen,” says Dr. Hoyer. “It’s been a simple intervention, but it’s helped drive change.”
Targeting more impaired patients
The next step is to determine how to mobilize patients who need just a bit of assistance. Dr. Hoyer and his team are designing an algorithm that incorporates both AM-PAC scores and the Johns Hopkins Highest Level of Mobility scale. And he just completed a study, which has not yet been published, that found those metrics to have “excellent reliability between nurses and physical therapists.”
“Once the algorithm is developed, we’ll be able to set daily patient mobility goals and put patients into different buckets, depending on how much assistance they need,” he says.
While there’s much more work to be done before early mobility becomes standard practice throughout the hospital, he added, “we’re at least demonstrating that a framework can increase the number of times that therapists can target more impaired patients with mobility efforts.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.