Increasing Mobility via In-hospital Ambulation Protocol Delivered by Mobility Technicians: A Pilot Randomized Controlled Trial

In this pilot study conducted with older medical inpatients, we found that assisted ambulation provided by a dedicated mobility technician was feasible and increased the number of steps taken by patients. Not all patients in the treatment group received the intervention partly due to the fact that the program initially did not include weekends and the mobility technicians were sometimes redirected to other nursing duties. Both issues were addressed during the course of the study. In the per protocol analysis, the intervention increased the average six-clicks score and there was a nonsignificant reduction in the percentage of patients discharged to a rehabilitation facility.

A range of hospital-based mobility interventions have been described. Several of which were complex multidisciplinary interventions that included a mobility component. The compliance rates have ranged from 82% to 93.7%,12,13 although a systematic review noted that many studies do not provide this level of information.¹¹ Interventions were carried out by nursing staff and PT with support from family members and social workers.^33-35 Ambulation-specific programs have also relied on nurses and PT13,14,36 and, occasionally, on research assistants to implement assisted ambulation protocols.^12,37 A recent study that employed research assistants to deliver inhospital ambulation reported achieving 51.3% of intended walks.³⁷

In contradistinction to previous studies, we created a new role, employing PCNAs as dedicated mobility technicians. We did this for two reasons. First, the approach is less expensive than deploying registered nurses or PTs to ambulate patients and therefore more likely to be adopted by hospitals, especially if it can decrease the cost of an episode of care by avoiding subsequent inpatient rehabilitation. Mobility technicians have no degree or certification requirements and are therefore paid less than nurses or physical therapists. Second, by having a single responsibility, mobility technicians were more likely to engage in their task than nurses, who have competing responsibilities. However, when nurse staffing was short, nurse managers were tempted to recall the PCNAs for other nursing duties. It took time before PCNAs and supervisors prioritized this new responsibility. When they did, the number of attempted walks increased substantially, but the percentage of successful attempts remained constant at 56%, highlighting the difficulty of getting hospitalized patients to walk.

On average, patients who received the intervention engaged in 72 minutes of additional physical activity and averaged 990 steps per day. Observational data suggest patients accrue about 1,100 steps in the day before discharge, with older patients accruing closer to 900.21 One study found that older patients with fewer than 900 steps per day were likely to experience a functional decline.32 We also found that patients who achieved at least 900 steps were more likely to go home. However, we found that a lower threshold, namely, 400 steps, offered better discrimination between patients who go home and those who do not. Future prospective studies are needed to establish the appropriate goal for exercise interventions. A lower step goal could dramatically enhance the efficiency of the intervention.

A Cochrane review found that pooled analysis of multidisciplinary interventions that included exercise, often in the form of walking, achieved a small but significant increase in the proportion of patients discharged to home (RR 1.08, 95%CI 1.03 to 1.14).¹¹ We found no significant change in the discharge disposition, but our study was underpowered for this endpoint. The six-clicks score showed a small but significant change in the per protocol analysis. The six-clicks score has been shown to correlate with discharge disposition,^28,29 and an improvement in the score suggests that discharge disposition may be influenced.

The intervention may also not have been implemented for long enough. On average, visits were achieved for one-third of the hospital stay partly because of the delay in PT evaluation, which we required for eligibility. In practice, PT evaluation can occur just a few days before the anticipated discharge. We observed a dose dependent response among patients in the intervention group, suggesting that earlier intervention could be more effective. Earlier intervention might be achieved if the MT performed the six-clicks on potentially eligible patients.

The effects of hospitalization on mobility may be the most pronounced in the long term; one study found that 40% of hospitalized older patients manifested new ADL or IADL disability three months after discharge compared with 31% at discharge.⁷ Hospital-based mobility interventions may continue to affect subjects’ independence for weeks or months. In one RCT, an inpatient ambulation intervention improved mobility in the community one month after discharge.³⁷ A hospital-based exercise program that included ambulation achieved better functional outcomes one month later.¹³ One RCT that combined inpatient exercise with outpatient care coordination also decreased readmission rates.³⁴ We found that the intervention did not affect readmission.

This pilot study has several limitations. The sample size was small, and the findings need to be replicated in a larger randomized controlled trial. This is particularly important because the two study arms were not balanced in terms of their prehospital activity. After adjustment for prehospital activity, the differences in the step count in the intention-to-treat analysis were no longer significant. As we adjusted the intervention to hospital workflow, the intervention changed over time. The intention-to-treat analysis may therefore underestimate the effect of the intervention. This work provides a basis for future trial. Finally, discharge disposition depends on a complex interplay of factors, including social factors and preferences, which may not be affected by a mobility intervention.

In summary, an inhospital mobility protocol of attempting ambulation delivered by dedicated mobility technicians three times daily successfully increased the daily step counts and mobility scores of the patients. Studies with a larger sample size are needed to determine whether the proposed approach can affect length of hospital stay, discharge disposition, and overall cost of an episode of care.