Part of the Age-Friendly Health Care Special Report
(Editor’s note: This story is part of a series for The John A. Hartford Foundation.)
In her work as the chief nursing officer for Anne Arundel Medical Center in Annapolis, Md., Barbara Jacobs recently found herself dodging a lot of patients walking in the corridor as she made her way down the hall.
“There were so many people up and moving, and that was a good problem to have,” she recalls. Jacobs is pleased that the hospital’s initiative of the past two years to keep patients — especially older ones — mobile during their time there is working.
Because staying mobile helps maintain muscle function and overall healing, it also reduces the risk of falls.
Like many hospitals around the country, Anne Arundel is recognizing the important role mobility plays in healing, reducing the risk of medical complications and ensuring that older patients will be able to return home after they’re discharged, rather than having to go a nursing home or rehabilitation facility.
Immobility Leads to Problems
“One of the things that is absolute is when a person becomes immobile, the loss of muscle tone is very, very quick — the actual loss of muscle mass is quick,” Jacobs says. “So, when a person comes into the hospital and becomes immobile, it’s significant — even if you’re young, you will go out feeling weak.”
And weakening muscles is just one of the negatives of being in a hospital bed for days.
“When we lay in a bed, our lungs are laying back against the back of our body,” Jacobs explains. “For maximum performance of our lungs, you’re supposed to be standing or sitting, where gravity is helping open our lungs. So, we’re more prone to developing pneumonia (and other respiratory illnesses) because our lungs are not in the position that they should be if we leave you in bed all day long.”
Immobility during a hospital stay is connected to a number of other problems, including frailty, falls and even death, “even after controlling for illness severity and comorbidity,” according to a 2018 article in the journal Gerontology and Geriatric Medicine.
Hospitalized older adults who remain mostly in bed are 34 times more likely to die and six times more likely to end up in nursing homes after their hospital stays than those who move around at least twice per day, according to research that included nearly 500 people age 70 and older.
Mobility Priority at Anne Arundel
In 2017, Anne Arundel Medical Center began its new mobility practices in the hospital’s geriatrics unit, which is an Acute Care for the Elderly (ACE) unit. Anne Arundel’s ACE unit is part of the hospital’s “age-friendly” initiative, with the goal of aligning care to what matters most to each patient.
Patients of all ages, inside and outside the ACE unit, who are able to get out of bed and move are encouraged to do so — ideally at least three times per day.
“It depends on the patient, obviously,” Jacobs says. “There are times when the person is too sick to get up. But for most people, they should be getting up and mobilizing as far as they can every day.”
That means doing some walking, even if it’s only a short distance.
“If the farthest you can get is walking from your bed to the door, great,” Jacobs says. “If you only go from the bed to the door two times today, but the next day you go fifty feet, that’s great.”
To help get patients moving, Anne Arundel has people called “mobility quality technicians,” whose main job is to ensure that patients who are able to move do so daily.
Movement and Socialization With ACErcise
The ACE unit also launched “ACErcise,” a group exercise program that Jacobs says is popular with patients. The groups do chair exercises and walk to and from their hospital rooms. Other hospitals around the country with ACE units have similar programs.
“Part of what makes it great is the socialization of being together,” Jacobs says. “Then, we had some (patients) who said, ‘Can we just eat together?’ So, after ACErcise, we put up a table and they can eat together.”
This emphasis on mobility has been important to patient Cline Warren’s recovery, says his wife Martha Warren. The couple live in southern Anne Arundel County. Cline Warren, 91, who has dementia, was brought into the hospital after he accidentally ingested a caustic substance.
“He’s much better,” Martha Warren says, adding that along with the exercise, the socialization aspects have been especially helpful. “It certainly contributes to being less bored — you know, being in your room alone. And (it helps to) be able to focus on other patients or the activity director.”
At St. Mary Mercy Livonia, a hospital in the Detroit suburb of Livonia, hospitalized patients have been staying active through “Mobility Optimizes Virtually Everything,” or MOVE, since 2017.
“As I was researching this topic prior to implementation of MOVE, I found out that every day a person spends in the hospital bed can take up to four days to regain their strength,” said program manager Belinda Dokic, adding that the hospital implemented MOVE because “mobility can also be a medicine.”
As part of MOVE, each patient receives “personalized mobility goals,” which nurses and aides review daily with patients.
MOVE began in St. Mary Mercy’s observation unit. This included adding full-time ambulation aides who were trained by the hospital’s physical therapists on how to safely move patients to avoid falls and injuries. Toward the end of 2018, the hospital added MOVE to its medical/surgical unit.
The goal of MOVE is to walk patients twice per day. Patients who are unable to walk are encouraged and helped to at least move from their bed to a chair for some period of time during the day.
“Any movement is good.” Dokic says. “Even if the patient is laying in bed and we (adjust) the bed for them to sit up and eat (a meal) that way, or we move them from bed to chair or even help them walk from a chair to the shower — all of this is considered movement.”
Mobility Helps With Fall Prevention, Too
Because staying mobile helps maintain muscle function and overall healing, it also reduces the risk of falls. This is something Dokic has seen at St. Mary Mercy, where the patient falls rate in the two units with the MOVE program decreased from 2.7% to zero from the last quarter of 2017 to the first quarter of 2018.
For some, more movement brings concern of more risk of falls, but a study led by Johns Hopkins Hospital researchers in 2016 found that increasing patient mobility did not increase the number of patient falls with injuries.
St. Mary Mercy carefully trains its ambulation aides, Dokic says. “I think it was four hours of training, where they were shown how exactly to move the patients without putting them at risk to have a fall,” she says.
Patient and Family Buy-In
Nurses and other staff working on mobility programs occasionally encounter concerned family members who believe their parent or other loved one shouldn’t be moving around while in the hospital.
“The family member might say, ‘Well mom’s been sick. Just let her rest in bed,’” Jacobs says. “But we’re actually not helping mom if we just let her rest in bed the whole time. So we have to actually say to the families, ‘No, this is an important part of your mother’s healing, that we get up and ambulate with your mom.’”
Staff also encounter patients who would rather not get up, understandably, because they don’t feel well. In that case, Jacobs says, it’s important to remind patients and families that remaining immobile could lead to a longer hospital stay, or worse.
“There’s a question we ask everybody every day (in the ACE unit), and that’s ‘What is it that really matters to you?’ This is part of our age-friendly work,” Jacobs says. “And the majority of patients answer that they want to get home. Well, the best thing we can do to get you home is to keep you moving. So, if that’s your plan, let us help get you there.”
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