I-MOVE gets elderly patients on the move

The I-MOVE sounds like a state-of-the-art electronic gadget, but it's actually the simplest of medical tools. Developed by clinicians at Mercy Hospital of Pittsburgh and the Mayo Clinic in Minnesota, the Independent Mobility Validation Examination, or I-MOVE, is a 12-point scale that could help hospitalists assess their patients' mobility.

Scores on the I-MOVE scale range from 1 (patient needs assistance to turn in bed) to 12 (patient can walk independently in the hallway) with steps in between for sitting up, standing, transferring to a chair and walking. A physician or nurse leads a patient through the steps on the scale and then can use the resulting score to answer questions like whether a patient has lost function or is ready to return home after discharge.

The I-MOVE scale From “Home alone: assessing mobility independence before discharge” Manning DM, Keller AS, Frank DL J Hosp Med April 2009 © 2009 Society of Hospital Medicine Reprinted with permission of John Wiley & Sons, Inc
The I-MOVE scale. From “Home alone: assessing mobility independence before discharge.” Manning DM, Keller AS, Frank DL. J Hosp Med. April 2009. © 2009 Society of Hospital Medicine. Reprinted with permission of John Wiley & Sons, Inc.

An assessment of the I-MOVE, which found it to have high face validity and interrater reliability, was published in the April 2009 Journal of Hospital Medicine. Although the tool's impact on outcomes has yet to be studied, Mayo hospitalists Dennis M. Manning, FACP, and A. Scott Keller, FACP, have high hopes for it, as they recently told ACP Hospitalist.

Q: What motivated you to develop the I-MOVE tool?

A: Dr. Manning: I had a practice of geriatrics and non-invasive cardiology. We were planning to discharge [a patient when] a caregiving daughter called me up in the office and said, “What do you mean she's going home? She can't get to the bathroom on her own.” This elderly person was previously very independent.

I thought, “Her pneumonia's getting better; her creatinine's getting better,” but what was very important was whether she still had the functional mobility that she used to. It struck me that I'm not certain that I do know whether a patient has independent mobility preserved or not.

We usually examine the patient right there in the bed and we don't usually walk the patient around every day. We are relying on information from the nurses or occupational therapists to let us know if the patient has crossed the threshold from independence to dependence, which is a pretty small shift in a frail elderly person who lives alone.

Q: How did that experience lead to the I-MOVE?

A: Dr. Manning: It caused us to think, “Could we have a more standardized tool to help us provoke a little bit of movement and observe it either as a physician or a nurse?” Everybody turns over in bed; pretty much everybody tries to sit up; pretty much everybody tries to stand, maybe transfers to or sits in the chair and then walks around. That's a pretty universal thing and it's sort of a hierarchical ability. If you can't get out of bed, then you can't walk in the hall for the most part.

Q: What was involved in developing the tool?

A: Dr. Keller: Part of what I helped Dennis with was reviewing the literature. By and large, many of the validated assessment tools that are used by physical therapists are somewhat cumbersome and more time-consuming than the typical hospitalist or clinician can take advantage of. Some of them are complicated.

But the I-MOVE, when you look at, it's so simple and clear-cut. You go from the basic movement of someone who's just trying to get their strength back up to someone who's walking independently and it's a graded skill. You count the points.

Q: Would the I-MOVE need to be performed daily on hospitalized patients?

A: Dr. Manning: Right now we're sort of in a dose-finding stage to see how often to do it. We did it for a while in our geriatrics service, and we found that it's doable daily because it doesn't take up much time. It wouldn't have to be done every day, but it could.

If you see the patient getting around real smartly, that's pretty clear-cut. In the patients who are low functioning, maybe just [perform the test] at some critical junctures in the patients' care, like at admission or any time that you're getting ready for discharge planning, or any time there seems to be a real change in their course.

Q: Once you have an I-MOVE score, what do you do with it?

A: Dr. Keller: For example, if someone is hospitalized with pneumonia, if on hospital day two or three their I-MOVE score is very low, the [physician] will need to get physical therapy involved sooner and need social services to look at possible nursing home placement.

Dr. Manning: We've actually employed it in a number of ways. [The score] gives us language to communicate. Somebody will say, “They're good to go. Their I-MOVE score is 12” or “Whoa, we've got a problem. Their I-MOVE score is about 4 and they're supposed to be going home alone. Maybe we better hold the process up.” We've seen some instances where it's caused us to think again about our plan.

We've used it on some of the resident teaching services to encourage learners to take a little more proactive role in assessing whether their patient can move about in the room and to correlate that with what occupational therapy might be finding.

Q: How could I-MOVE affect patient outcomes?

A: Dr. Keller: Our hope is that using something like the I-MOVE score can help maybe identify these people early to get therapy so they can avoid the nursing home. Also, if [nursing home care] were inevitable, we would have objective evidence for patients and family members. Sometimes seeing something objective like that could also convince that patient and family that a nursing home stay is not a bad idea to get rehabilitative therapy.

Dr. Manning: We think it could also be in some way a measurement of functional outcome. We have very few measures of functional outcome in a hospitalized patient. In some ways, the capabilities that are demonstrated in I-MOVE might be considered an outcome as well as a measure.

Q: How time-consuming is it?

A: Dr. Manning: It does take about four or five minutes. We think it's so simple to do that at those crucial junctures of care, it's a worthy extension of our physical exam, perhaps as important as routine listening to the lungs.

Dr. Keller: As the patient gets more functional, you don't really have to do a detailed I-MOVE exam. You just simply observe and you know the number. For example, if someone is walking in the hallway, they're an I-MOVE 12.

If they're very weak and debilitated, you might have to ask them, “Can you at least roll over on your own? Can you sit on the side of the bed?” Often, we do that during the physical exam anyway—for example, have someone sit up to listen to the lungs—so it may not really be an extra burden. To me, the beauty of this and the whole goal is to get a quick tool to help gauge fairly objectively someone's functional status without overloading the already busy clinicians in the hospital.

Q: Is the I-MOVE ready to be applied in other hospitals?

A: Dr. Manning: Anyone who reads our article can import [the I-MOVE] and use it at their hospital, perhaps in the way we've done it—screening—or perhaps for a larger study on how it correlates with other assessment tools or how it correlates with prognosis or how it correlates even as an early warning that something is going wrong, like sepsis or delirium. We think it is ready for others to use.