“I didn’t get out of bed for 10 days”
—Anonymous patient admitted to a skilled nursing facility post-hospitalization for a COPD exacerbation
Readmission penalties, “Medicare spending per beneficiary” under value-based purchasing, and the move to accountable care are propelling hospitalists to do more to ensure our patients recover well in the least restrictive setting, without returning to the hospital. As we build systems to support patient recovery, we are focused on a medical model, paying attention to managing diseases and reconciling medications. At the same time, there is a growing awareness that functional status and mobility are critical pieces of patient care during and post-hospitalization.
(click for larger image)Figure 1. Barthel Index.4
Regardless of principal diagnosis and comorbidities, patients’ functional mobility ultimately determines their trajectory during recovery. To illustrate the importance of functional status and outcomes, one study showed that models predicting readmission based on functional measures outperformed those based on comorbidities.1
The negative effects of hospitalization on patient mobility, and in turn, on recovery, have been recognized for a long time. Immobility is associated with functional decline, which contributes to falls, increased length of stay, delirium, loss of ability to perform activities of daily living, and loss of ambulatory independence. A number of studies have reported successful early mobility programs in critical care and surgical patients.2 Fewer have been reported in general medical patients.3 Taken together, they suggest that a program for mobilizing patients, using a team approach, is an important part of recovery during and after hospitalization.
The purpose of this column is to report the components of one healthcare system’s mobility program for general medical-surgical patients.
Early Mobility: A Case Study
St Luke’s University Health Network (SLUHN) in northeastern Pennsylvania has implemented an early mobility program as part of its broader strategy to reduce readmissions and discharge as many patients home as possible. Although the SLUHN early mobility program depends on nursing, nursing assistants, and the judicious use of therapists, physician leadership during implementation and maintenance of the program has been essential. Moreover, because the program represents a culture shift, especially for nursing, leadership and change management are crucial ingredients for success. Below are the key steps in the SLUHN early mobility program.
Establish baseline functional status. Recording baseline function is an essential first step. For patients admitted through the ED, nurses collect ambulatory status, patient needs for assistance, ambulatory aids/special equipment, and history of falls. They populate an SBAR (situation, background, assessment, recommendation) form with this information and, as part of the handoff, ensure that it is transmitted to the inpatient nurse receiving the patient.
Obtain and document Barthel Index score. SLUHN uses the Barthel Index (see Figure 1) to establish a patient’s degree of independence and need for supervision. The index is scored on a 0-100 scale, with a higher score corresponding to a greater degree of independence. SLUHN created three categories: 0-59, stage 1; 60-84, stage 2; 85-100, stage 3.
Patient mobility plan. Based on the Barthel-derived stage, a patient is assigned a mobility plan.
The role of nursing. The patient’s registered nurse is responsible for implementing the “patient mobility plan.” The nurse initiates an “interdisciplinary plan of care,” in which the mobility stage is written on the SBAR handoff report tool. The report is discussed at change of shift and at multidisciplinary rounds. Nursing also communicates the mobility plan to the nursing assistants and assigns responsibilities for the mobility plan (activities of daily living, out of bed, ambulation, and so on), including verifying documentation of daily activities and assessing the patient’s response to the activity level of the assigned stage.