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
Randomization
Patients were randomized to “usual care” or “mobility technician” after baseline evaluation using a computerized system. A block randomization scheme with a size of four was used to ensure an approximately equal number of patients per group.
Intervention
Patients randomized to the intervention group were asked to participate in the ambulation protocol outlined by the PT three times daily under the supervision of the mobility technician. The protocol involved four exercise levels (sitting, standing, walking, and stairs), which were implemented depending on the patient’s physical capacity. The mobility technicians, who were PCNAs, were trained by the PT team. PCNAs have no specific degrees or certification. They are taught safe handling techniques during their job orientation, so they already had an understanding of how to transfer and assist a patient with ambulation. The mobility technician training consisted of one four-hour session run by the PT team in the physical therapy department and the nursing unit. The training included safe handling practices and basic mobility, such as transfers from bed to chair, bed to standing, walking with assistance, and walking independently with equipment such as cane, rolling walker, and walking belt. All instruction was demonstrated by the trainer, and the mobility technician was then able to practice. The mobility technician then shadowed the trainer and practiced the techniques under supervision. Competency was assessed by the trainer.
The cohort of patients randomized to “usual care” was not seen by the mobility technicians but was not otherwise restricted in nursing’s baseline ability to execute recommendations placed by the PT team. Compliance with the recommendations is highly variable and dependent on patient acuity during the shift, staffing issues, and competing duties. Cleveland Clinic promotes a “culture of mobility,” and nurses are encouraged to get patients out of bed and assist with ambulation.
Study Instruments—Measures of Mobility
The six-clicks instrument is a tool for measuring basic mobility. It was adapted from the Activity Measures for Post-Acute Care (AM-PAC) instrument.25 Although initially created for self-report in the post-acute care setting, six-clicks has been validated for use by PTs in the acute care setting26 and is currently in use at more than 1,000 US hospitals. Cleveland Clinic PTs have used this measure for routine evaluation since 2011. The instrument has high interrater reliability and can predict discharge disposition.27-29
Each patient was provided with a tracking device (Fitbit) attached at the wrist to record daily steps for measuring mobility. The use of Fitbit has been validated in ambulatory and inpatient settings.30 The device produces step counts within 3% of the observed step count for most patients but may undercount steps in patients with very slow gait.31 The device was provided to each enrollee and collected at discharge.
Variables
Demographic information, comorbid diagnoses, and discharge destination were extracted from the electronic medical record. Information on prehospitalization physical activity level was obtained from the initial PT assessment. Falls were tracked through the safety event reporting system.
Outcomes
The primary outcomes were discharge disposition and hospital length of stay. The secondary outcomes included average steps per day, change in six-clicks score from admission to discharge, inpatient mortality, admission to ICU, falls, deep vein thrombosis, pulmonary embolism, or pneumonia, and readmission within 30 days.
