In 2012, a healthcare group of 21 medical centers embarked on a project to prevent hospital-acquired pneumonia (HAP) in nonventilated patients. The project included the introduction of an intervention bundle, which targeted out of bed mobility and ambulation. In 2013, the Enhanced Recovery After Surgery project, which also encompassed early and frequent patient ambulation, was implemented at the same group of medical centers. Many of the nursing staff expressed concerns that by increasing their patients' mobility, there would be an increase the number of patient falls. A balancing measure was added to these projects to track the number of falls against the increased rates in ambulation. Many authors have cited fear of patient falls as a limiting factor to patient ambulation.1-3
INTRODUCTION
Inpatient falls are the most commonly reported adverse event in hospitals. Injury from a fall may have serious physical and psychological consequences, including the need for a surgical intervention, prolonged hospitalization, additional pain, and the fear of future falls. A review of fall data from 2006 to 2008, submitted to the National Database of Nursing Quality Indicators, validated that the overall fall rate in US hospitals averages 3.53 per 1000 patient days, with fall rates higher in medical units than on surgical or mixed medical/surgical units. Patient falls that resulted in major injury represented 4.3% of the fall events.4
Immobility can cause pressure ulcers/pressure injury, deep vein thrombosis (DVT), loss of muscle mass, and a decrease in long bone density. The latter 2 complications can have a profound impact on the patient's capability to attain a stable standing posture and the ability to walk. The cardiovascular impact of immobility contributes to the body's ability to regulate blood pressure with position changes, regardless of medication administration, which may cause orthostatic dizziness. Over the past 40 years, the therapeutic use of bed rest as a treatment option has lessened and is being replaced with a targeted focus on enhancing the patient overall health with early ambulation and mobility.1-3,5,6
NURSING DECISION MAKING REGARDING MOBILITY
In 2007, a 2-part nursing study was conducted by Dr Barbara Doherty-King and Dr Barbara Bowers at large mid-Western hospitals to identify the factors that influence the decision-making process of nurses related to the ambulation of hospitalized elderly patients.1 This study used grounded dimensional analysis to explore nurses' understanding of the benefits of ambulating their patients and how their understanding related to the actions taken to ambulate their patients.1 From the analysis of these studies, a conceptual model of how nurses decide to mobilize patients was developed.1
Three drivers for mobility were identified: the prevention of complications, monitoring of progress, and compliance with physicians orders.1 Nurses interviewed saw mobility as a means to another end, not the end itself. Mobility was not always recognized as a primary prevention strategy for DVT or pneumonia because other tools such as sequential compression devices or incentive spirometer were more widely promoted for prevention of complications.
The level of mobilization was dependent on several factors, including where the nurse felt the patient was in their hospital trajectory, the patient's discharge plan (such as whether the patient would be sent home or to a skilled nursing facility), and a risk/opportunity assessment.1
If the patient was acutely ill, out-of-bed activities are generally avoided until the patient was considered stable or in the recovery mode. Although some mobility, including ambulation, occurs during the recovery phase, increased ambulation may not occur until the "getting ready for discharge" phase.1 According to the researchers, the "getting ready for discharge" phase is generally short and is frequently not well planned in advance.1 Significant deconditioning can happen by time of discharge planning, requiring the involvement of physical therapy (PT) or possible transfer for rehabilitation instead of returning home.
Another factor was the nursing risk/opportunity evaluation, which is often done as part of the decision-making process for ambulation. Perceived risks could include physical injury to the patient (eg, a fall) and/or injury to the staff member. An opportunity evaluation could include the availability of resources such as time and staff assistance. The higher the perceived risk or the lower the opportunity for ambulation decreased the likelihood of mobility.1
A part of the risk/opportunity assessment, which was explored in more depth in a subsequent secondary analysis of the data, was the relationship between a nurse's attribution of responsibility to ambulate and his/her decision to ambulate a patient.7 Nurses who owned the responsibility for ambulation focused on patient independence and psychosocial well-being. They took specific actions such as collaborating with PT, determining the appropriate activity orders, diminishing risks, and adjusting available resources. Nurses who attributed the responsibility of ambulation to other staff members deferred decisions about initiating ambulation to either PT or physicians. These behaviors included waiting for PT clearance, waiting for risks to decrease or resources to improve, and not requesting changes in physician's orders. They tended to wait for signs of physical or cognitive improvement before initiating ambulation and justified not ambulating when time was constrained.7
Finally, Doherty-King and Bowers1 found that clear expectations of roles in combination with some form of accountability had a significant impact on mobilizing patients. Accountability was achieved when mobilizing patients was made visible to others and when there were consequences for not mobilizing patients.1 This factor was more powerful than nursing perception of responsibility in determining that patients were mobilized, often overriding that perception.7
FALL PREVENTION PROGRAM
Beginning in 2007, inpatient fall prevention strategies were implemented by a healthcare group of 21 medical centers. A bundle of interventions were introduced using the TEAM acronym: "T" for toileting, "E" for environment, "A" for activity, and "M" for medication management. In 2011, revisions were made to the fall prevention program to include "Universal Fall Precautions." In these Universal Fall precautions, mobility was promoted to prevent deconditioning.
MOBILITY PROGRAM
In 2012, 3 quality improvement projects were implemented across the 21 medical centers. All targeted early and progressive mobility as the primary intervention. A formal mobility protocol was developed and approved by nursing and physician leaders to support the 3 projects. The protocol is based on progressing mobility to failure, measured by what the patient can accomplish, rather than each step building on gains from previous steps. For example, if the patient can hold a lower extremity off of the bed surface, he/she is moved to a seated position on the side of the bed. If the patient can maintain balance sitting on the side of the bed, he/she is assisted to the standing position. If the patient can stand, he/she is encouraged to march in place. If this can be accomplished, the patient is walked with an initial goal of 50 ft and a target goal of 200 ft.
One of the projects was "Rethinking Critical Care," which focused on patients in the intensive care unit and instituted a target for once a day ambulation of 20 ft or more for 35% of all appropriate patients. Patients excluded from the measure were those whose prehospital level of function was bed or chair bound (2 weeks before admission). The target was increased to 40% of all appropriate patients for 2015.
A second project was the HAP prevention project, launched in 2013 on all medical/surgical/telemetry units. Progressive mobility was an integral component of the HAP project. The initial ambulation target was for 50% of all appropriate patients to ambulate 20 ft or more twice a day. Patients excluded from the measure were those whose preadmission level of function was bed or chair bound (2 weeks before admission). The ambulation target was raised to 60% for 2014 and 65% for 2015. The impact of this specific program is the basis for this article.
Lastly, the Enhanced Recovery After Surgery project was launched in 2014. The goal of this project was to optimize patient recovery from surgery and included early and progressive mobility.8,9 The project began in the 21 medical centers for patients undergoing colorectal surgery and hip fracture repair and has since expanded to include hip and knee replacement surgery.
The HAP project included additional mobility-related elements such as developing hallway ambulation distance markers and assessing human resources for mobility. Depending on the medical center, the distance markers were either on the wall or on the floor. One medical center placed their markers, a stylized flower, on the wall near the ceiling. A few medical centers replaced floor tiles at designated intervals and 1 medical center created decals of a person walking that were placed on the floor.
To increase the human resources needed for ambulation, the patient care technicians were empowered to become the unit's mobility champion. Tasks related to mobility, assisting with bed mobility, helping the patient out of bed to a chair for meals, and providing support with ambulation were designated as the number 1 priority for these bedside care providers. Documentation of distance walked and other out-of-bed activities by either the nurse or the patient care technician appears in the same row in the electronic medical record.
To determine the rate of ambulation, a regionally based data analyst created a report on the frequency and distance of daily for each unit. The numerator is the number of patients meeting the ambulation metric definition. The denominator was all medical/surgical/telemetry patients with a preadmission mobility that included the ability to walk. Recognizing that not all patients on a medical/surgical or telemetry unit would be able to walk, the target was initially set at 50% for the HAP project.
Some medical centers created local tools to track ambulation. These were often pen and paper tools. One medical center developed a daily reporting tool from the electronic medical record to identify those patients who had and had not walked. Each nursing manager received this daily report and used them in staff huddles to identify barriers and/or challenges that prevented ambulation. This tool led to the development of a regionally created daily report, available for every medical/surgical and telemetry unit in all 21 medical centers. This ambulation report is sent automatically via e-mail to every unit manager. The ambulation report identifies which patients met the ambulation target, patients who were excluded from the measure, and those who did not meet the target. With this report, nursing managers have the ability to hold the staff accountable for ambulating patients. Being able to hold staff accountable for ambulation was a highly effective driver to increase ambulation rates.
RESULTS
In 2013, the twice-a-day ambulation baseline rate across the 21 medical centers was 18%. At the end of 2015, the ambulation rate had increased to 65%. Plotted on a trend chart, the fall rates over the same period demonstrated a mean of 2.25 per 1000 patient days. Although there were some months with higher fall rates, the increase was not statistically significant. In medical centers with ambulation rates consistently at target and for those where mobility was increased, there was not an increase in the fall rate.
CONCLUSIONS
Increasing patient mobility did not lead to an increase in the falls across the 21 medical centers. Building a default physician's order for implementation of the mobility protocol, which included a thorough assessment of the patient's ability to mobilize and having an accountability tool, was integral to the successful increase in ambulation. In addition, with the increased out-of-bed mobility, in particular patient ambulation, fewer patients developed pneumonia during hospitalization.
RECOMMENDATIONS
The clinical nurse specialist (CNS) is an important change leader for programs that promote patient mobility and fall prevention. As a clinical expert, the CNS can assist in the development and consistent implementation of mobility programs that do not rely on an evaluation or recommendations by a physical therapist. Advanced clinical assessment skills place the CNS in a position to recommend strategies to protect patients from falls as out-of-bed mobility is optimized. The CNS has a significant consultative role in efforts to sustain mobility and fall prevention performance improvement projects. The CNS also plays a key role in leading teams while keeping the clinical, quality, and patient needs at the forefront of the change efforts.9 In the role of educator, the CNS also identifies postimplementation learning opportunities, often using data and patient stories.9 When drift from practice is identified, the CNS is often the first nursing leader to engage the staff in identifying strategies to reengage and renew the efforts to increase and/or maintain ambulation and reduce falls. The fear of an inpatient fall should not limit mobility; it should encourage it. If Humpty Dumpty had been walking, would he have had a fall?
References