Muscle weakness, muscle loss, and delirium are just a few of the complications that often arise when a patient remains immobilized in a hospital bed. 

"And the decline in functional status can really occur as early as day 2 of hospitalization," said Marla Robinson, MSc, OTR/L, director of inpatient therapy services for UChicago Medicine in Illinois.

Meanwhile, numerous studies suggest that early mobilization is associated with favorable outcomes, such as improving functional independence, reducing ICU length of stay, preparing patients to be discharged to their homes instead of a skilled nursing or rehabilitation facility, and even improving 30-day mortality rates. Mobilization is also a key component of the 4Ms of Age-Friendly Care, the framework that guides Age-Friendly Health Systems, with CMS promising incentives to hospitals to provide care to older adults that integrates the 4Ms. 

But while the consequences of prolonged immobilization and the benefits of mobilization are well documented, standardized mobility care programs are not widespread in the US. That needs to change, many experts say, because getting a patient up and moving can't be left to chance. To combat hospital-associated functional decline, more hospitals need to implement standardized mobilization programs that can be tailored to a patient's individual needs. 

Changing the Approach to Embrace Mobilization 

One challenge to overcome is the traditional hospital approach to recovery, said Rajeeva Ranga, DO, regional medical director of hospital quality and acute inpatient service lines at Kaiser Permanente Northern California. He recently co-authored a case study for New England Journal of Medicine (NEJM) Catalyst Innovations in Care Delivery about Kaiser Permanente Northern California's implementation of a structured mobility care model in its 21 hospitals.

"Our traditional hospital model is for patients to stay in bed to rest and recuperate from an acute illness," he said. "Patients have the same mindset as well, that they are in the hospital to rest and get better from their medical illness."

Michael Friedman, PT, MBA, director of the Johns Hopkins Activity and Mobility Promotion program, agreed. "That concept still lives on in our society," he said. 

Additionally, hospitals can face financial penalties for injuries as the result of preventable falls, which could be a deterrent to both staff and patients when it comes to mobilization. 

"Falls are supposed to be 'never' events, and staff are afraid of patients falling and injuring themselves," said Lauren Gleason, MD, MPH, who specializes in geriatric and internal medicine and is an associate professor of medicine with UChicago Medicine.

When Yale New Haven Hospital initially launched its STEPS-ICU mobility program in the medical ICU to drive earlier mobilization of patients, "people were fearful and apprehensive because these are really, really sick patients in the ICU," said Lauren Ferrante, MD, MHS, an attending physician in the hospital's medical ICU and an associate professor in pulmonary and critical care medicine at the Yale School of Medicine.

The hospital intentionally created a multidisciplinary leadership team with physicians, nursing, and rehabilitation services all contributing equally, according to Ferrante. As the leadership team continued to offer evidence-based education, team members became more comfortable. 

Now, any ICU staff member will confidently say, "'Mobility is what we do here,'" Ferrante said. "It took time and investment to achieve that."

The Value of a Standardized Model 

Many organizations do understand the value of mobilizing patients in the hospital, but their actual efforts often boil down to just encouraging patients to "move more" or other shortcuts, Friedman said. By contrast, those who embrace a systematic approach with a standardized quality-improvement process can move the needle on improving hospital-associated decline that's linked to immobilization. 

"People would say, 'We move people fine,' and I would say, 'How do you know?'" Friedman said. "You need a measurement system, but it needs to be a good measurement." 

The Johns Hopkins Activity and Mobility Promotion program is frequently used as a model for hospitals when it comes to creating and implementing a standardized approach to patient mobilization. The Northern California Kaiser Permanente team reviewed the Johns Hopkins eight-step hospital mobility framework for guidance on how to successfully structure a broad-scale initiative that focused on improving mobilization. 

They implemented a new, streamlined assessment tool called the Physical Function Five (PF5) that was integrated into core activities that care teams were already performing. That formed the foundation for the development of the Patient-Specific Mobilization (PSM) program. Then they improved their electronic medical record's (EMR's) functionality to automatically interpret the PF5 results to provide clear, immediate guidance on mobilization for each patient to their care team members. 

"That reduced the burden of interpretation and helped to increase care team understanding of the appropriate level of mobilization for the patient, frequently cited as a reason for reduced levels of mobilization," Ranga said. 

After implementing the PSM model, the 21 Kaiser Permanente Northern California hospitals experienced a 12-point improvement in appropriate patient mobilization, according to the NEJM Catalyst Innovations in Care Delivery case study. 

UChicago Medicine has also leveraged its EMR to help team members at the bedside, according to Robinson. The goal is to mobilize patients three times within a 24-hour period, but each patient needs different amounts of support to reach that goal. 

Upon admission, nurses assign a mobilization score to patients, using the Activity Measure for Post-Acute Care (AM-PAC) assessment, too. Team members can easily view each patient's score, which is updated every shift, in their EMR and provide the appropriate support for mobilization. 

"It helps us to triage or prioritize where we put our resources," said Robinson. 

Leadership support is crucial for the success of this type of program, but so is buy-in from front-line staff, according to Joeffrey Hatton, MBA, associate regional administrative officer for alternatives to hospital care for Kaiser Permanente Northern California. Engaging front-line staff throughout the entire process, including designing and implementing the PF5 scores into mobility targets, was also deemed essential for the hospital system.

"Our focus throughout the patient-specific mobilization effort was to make it as easy as possible for our care team members to do the right thing for our patients," he said. 

"Engaging the team as they develop a program is really important in order for it to be successful," Robinson agreed. "People need to understand the 'why.' And their workflows need to be acknowledged in the development of it." 

No reported disclosures.