Where: Two 24-bed general medicine units at the Johns Hopkins Hospital, a 1,145-bed academic medical center in Baltimore.
The issue: Improving mobility in inpatients.
Getting up and moving around boosts strength and vitality, yet patients tend to stay horizontal for much of their time in the hospital. “We lay you down, you can eat all your meals in your bed, you could go to the bathroom in your bed, and you could literally get away with not getting upright at all. And we know physiologically, that starts to affect you in 72 hours,” said Michael Friedman, PT, MBA, director of rehabilitation services at the Johns Hopkins Hospital.
Research suggests a link between extensive bedrest and adverse effects on mobility, such as difficulty performing activities of daily living, he noted. This decline in physical function can also result in increased length of stay.
Piggybacking on their earlier work in the ICU, which aimed to get patients up and moving and reduced length of stay and delirium, a team of physicians, nurses, rehabilitation therapists, and administrators embarked on a quality improvement project in 2 general medicine units. “The thought was, ‘If we can get our most sick, complicated patients up and moving in the ICUs, we should be able to do a better job on the floors,’” Mr. Friedman said. “What was actually being shown was we were doing worse on the floors than the ICUs because the work that needed to be done to really engage our patients to move is split up among a number of providers.”
How it works
As part of the project, nurses mobilized patients 3 times a day, setting movement goals along the way and tracking patients' progress. To document mobility, the team came up with a novel metric, the Johns Hopkins Highest Level of Mobility (JH-HLM), which was integrated into the electronic medical record. “There's a lot of vague terminology that's used: ‘The patient's out of bed or walking.’ But you don't really know exactly what that means,” said Erik Hoyer, MD, an assistant professor and deputy director for patient safety at the department of physical medicine and rehabilitation. The JH-HLM, a simple yet specific scale ranging from 1 (only lying down) to 8 (walking 250 feet), was key in helping clinicians create mobility goals, gauge patients' progress, and communicate about these issues, Mr. Friedman said.
During the yearlong project, unadjusted median length of stay dropped to 3 days compared to 4 days during the prior 12 months, according to results published in the May Journal of Hospital Medicine. The percentage of patient-days in which patients ambulated increased from 43% during the ramp-up phase to 70% after the intervention, and the percentage of patients who improved their mobility scores between admission and discharge increased from 32% to 45%. Additionally, no association was seen between increased mobility and injurious falls on the units.
The nurses correctly documented mobility about 85% of the time, the study found. “They were documenting this as a vital sign, and we worked with our informatics teams to pool the data so that we could start having some reports of compliance because that's a great way to create accountability,” Dr. Hoyer said.
The hospital did not hire additional workers to handle the mobility project, so a challenge was using existing resources to change practice, Mr. Friedman said. And getting the nurses on board took a bit of convincing. When the team explained the new scale, the nurses weren't thrilled because of their existing documentation workload, Mr. Friedman said.
To address this, every time the team added something to the nurses' workflow, they had to remove something else, he said. “We got them to buy in to using 1 tool because we got rid of 3 other tools,” he said, noting the JH-HLM was able to meet regulatory requirements and thereby supplant other documentation tasks. “That was a big deal to nurses and ended up being 1 of the reasons they bought in,” Mr. Friedman said.
There were also very basic challenges, such as not having enough chairs for newly mobile patients to get into. “So administration had to come up with money to do it, but when you look at those dollars versus saving 1 readmission or 1 fall, it clearly made sense,” he said.
Now that mobility scores have become a part of life on these units, the team is interested in utilizing mobility metrics to streamline care for patients across the continuum of care, Dr. Hoyer said. “We're focusing here on a medicine population, but this really has broad applicability in the hospital setting to postsurgical patients, cardiac patients, [and] neurological patients...then afterward, as well, in different settings like home care and skilled nursing facilities,” he said.
The next step is to engage families, which are an important but underutilized resource in encouraging patient mobility, Mr. Friedman said. “I think the biggest thing physicians can do is reinforce with patients and families how important getting up is while they're rounding....If the hospitalists can come in and engage a family or patient to get up multiple times throughout the day, then you can focus the therapists and the nurses on the more ill patients on the unit,” he said.