In 2006, studies by Dale Needham, medical director of the Johns Hopkins Critical Care Physical Medicine and Rehabilitation Program, showed that even the sickest patients in the intensive care unit can benefit from early mobility, such as standing or walking. Since then, efforts have intensified across The Johns Hopkins Hospital to promote such mobility on all inpatient units, thanks to the Activity and Mobility Promotion (AMP) initiative, co-directed by Michael Friedman, director of rehabilitation therapy services, and Johns Hopkins physiatrist Erik Hoyer.
Friedman says that patients spending too much time in bed has been linked to mortality and complications. “Immobility is a preventable harm—no different from pressure ulcers, falls or deep vein thrombosis.” And, he adds, every staff member involved in caring for patients needs to help ensure that mobility is a priority and that patients move as much as possible each day.
In a recent study in the Journal of Hospital Medicine, Friedman and Hoyer found that increasing daily mobility to three times a day resulted in significantly improved walking ability for more than 3,300 patients. Over the course of a year, the number of patients achieving the highest level of mobility—walking at least 250 feet—increased from 43 percent to 70 percent.
Much of the success comes from the joint efforts of all the patients’ care providers. Not long ago, when doctors wanted their patients to get up and out of bed, a nurse would call a physical therapist. But there are not enough physical therapists to accommodate that daily need. Often this would result in several days passing without getting patients out of bed or walking. Hoyer and Friedman say that with proper guidance, nurses, physicians, technicians and family members can play a pivotal role in restoring patients’ ability to perform such activities as brushing their hair and walking to the bathroom.
“People need to recognize that patient mobility is important,” says Hoyer. “And all members of the care team need to use a common measure for it. They need to speak the same language to help determine which patients are starting to decline.” To that end, as part of the AMP initiative, Hoyer, Friedman and occupational therapist Annette Lavezza have created an easy-to-use, daily mobility goal guideline to chart progress and identify risk for each person (see sidebar).
The program requires buy-in from nurses, physicians, therapists and patients, and it’s not always an easy sell. Barriers include the perception that patients are too sick to be moved or that they might fall. “But inactivity itself is a major cause for falls,” says Hoyer, explaining that patients are vulnerable as they try to recoup their bearings.
Under the guidelines set up by Hoyer and Friedman, nurses meet regularly with therapists to discuss how to advance mobility and to review plans for discharge. An 86-year-old woman living alone, for example, needs to be assessed carefully to ensure that she can get around her home safely, says Hoyer. If not, she should receive additional rehab services or be considered for placement in an assisted living facility.
Hoyer and Friedman believe that creating “a culture of mobility” is possible. Just as the ubiquitous hand-washing campaign resulted in greater compliance, says Hoyer, “raising awareness about getting patients moving every day can prove transformative for them.” He and Friedman are available to give presentations on patient mobility.
The mobility program is patient-centered, and it raises patient satisfaction, they’ve found. Says Friedman, “It adds up to being able to get out of bed, go to work, go to the grocery store, make meals, or, over time, even run a 5K—meaningful milestones to our patients.”