Increasing Mobility via In-hospital Ambulation Protocol Delivered by Mobility Technicians: A Pilot Randomized Controlled Trial
BACKGROUND: Ambulating medical inpatients may improve outcomes, but this practice is often overlooked by nurses who have competing clinical duties.
OBJECTIVE: This study aimed to assess the feasibility and effectiveness of dedicated mobility technician-assisted ambulation in older inpatients.
DESIGN: This study was a single-blind randomized controlled trial.
SETTING: Patients aged ≥60 years and admitted as medical inpatients to a tertiary care center were recruited.
INTERVENTION: Patients were randomized into two groups to participate in the ambulation protocol administered by a dedicated mobility technician. Usual care patients were not seen by the mobility technician but were not otherwise restricted in their opportunity to ambulate.
MEASUREMENTS: Primary outcomes were length of stay and discharge disposition. Secondary outcomes included change in mobility measured by six-clicks score, daily steps measured by Fitbit, and 30-day readmission.
RESULTS: Control (n = 52) and intervention (n = 50) groups were not significantly different at baseline. Of patients randomized to the intervention group, 74% participated at least once. Although the intervention did not affect the primary outcomes, the intervention group took nearly 50% more steps than the control group (P = .04). In the per protocol analysis, the six-clicks score significantly increased (P = .04). Patients achieving ≥400 steps were more likely to go home (71% vs 46%, P = .01).
CONCLUSIONS: Attempted ambulation three times daily overseen by a dedicated mobility technician was feasible and increased the number of steps taken. A threshold of 400 steps was predictive of home discharge. Further studies are needed to establish the appropriate step goal and the effect of assisted ambulation on hospital outcomes.
© 2019 Society of Hospital Medicine
Individuals aged 65 years and over represent 13% of the United States population and account for nearly 40% of hospital discharges.1 Bedrest hastens the functional decline of older patients2-5 and is associated with risk of serious complications, such as falls, delirium, venous thrombosis, and skin breakdown.6,7 Ambulation is widely recognized as important for improving hospital outcomes.8-10 Observational studies suggest that increases of 600 steps per day are associated with shortened length of hospital stay.9 However, randomized trials of assisted ambulation have not demonstrated consistent benefit.11-14 As a result, usual care at most hospitals in the United States does not include assisted ambulation. Even when ambulation is ordered, execution of the orders is inconsistent.15-17
Studies have demonstrated the benefits of various exercise protocols for older patients in rehabilitation facilities,18,19 medical intensive care units,20 and medical and surgical wards.13,18,21 These interventions are usually nursing centered; however, assisting patients with ambulation multiple times per day may be a burdensome addition to the myriad responsibilities of nurses.19,22,23 In fact, ambulation orders are the most frequently overlooked nursing task.24
We designed a graded protocol of assisted ambulation implemented by a dedicated patient care nursing assistant (PCNA) multiple times daily to increase patient mobility. The objective of this study was to assess the feasibility and effectiveness of such an intervention for older inpatients. We hypothesized that the intervention would prove feasible and improve hospital outcomes, including less need for inpatient rehabilitation and shorter length of stay.
METHODS
We conducted a single-blind randomized controlled trial of patients aged ≥60 years and admitted as medical inpatients to the Cleveland Clinic Main Campus, a tertiary care center with over 1,440 inpatient beds. The consent form and study protocol were approved by the Cleveland Clinic Institutional Review Board, and the study was registered with ClinicalTrials.gov (NCT02757131).
Patients
All patients who were admitted to study wards for a medical illness and evaluated by Physical Therapy (PT) were eligible for the study. PT evaluations were ordered by the medical team if deemed necessary on the basis of factors, such as age, estimated mobility, and concerns raised by the ancillary staff. All patients who were expected to be discharged to a skilled nursing facility placement or who required home PT received a PT evaluation. Assessment of mobility was documented via Activity Measure for Postacute Care Inpatient Basic Mobility “six-clicks” short form, hereafter abbreviated as “six-clicks.” Based on past experience, patients with scores <16 rarely go home (<20% of the time), and those with scores >20 usually go home regardless of ambulation. Therefore, only patients with scores of 16-20 were invited to participate in the study. Although patients who were not evaluated by PT might also benefit from the intervention, we required a six-clicks score to assess eligibility. The exclusion criteria included anticipated remaining length of stay less than three days, admission under observation status, admission to the intensive care unit (ICU,) patients receiving comfort care measures, and patients with medical conditions precluding ambulation, such as decompensated heart failure or unstable angina.
