The benefits of mobility among hospitalized patients are well-known—decreased pressure ulcers, deep vein thrombosis, and functional decline—to name a few.
"Hospital-acquired pressure ulcers, falls in the hospital, falls that cause injury, DVTs, and pulmonary emboli are also caused by immobility," says Maggie Hansen, RN, BSN, MHSc, senior vice president, chief nurse executive at Memorial Healthcare System in Hollywood, Florida. "They have other factors that contribute to them, but [nursing] is taking ownership for preventing some of those things that should never happen to patients."
Still, finding the time to ambulate patients during a busy shift is something nurses often struggle to do.
"We heard feedback [from nurses] like, 'I really wish I had more time to ambulate my patients,'" says Leslie Pollart, RN, MSN, MBA, director of nursing at Memorial Regional Hospital in Hollywood, Florida. "While they knew it was important, competing priorities often impeded their ability to ensure timely patient mobility, and sometimes patients need more than one person to assist them in getting out of bed."
To address this issue and ensure patients were getting the ambulation they needed to achieve optimal outcomes, the hospital revamped its mobility program, including creation of a designated mobility team.
According to both Hansen and Pollart, the program has had numerous results.
Pollart says lower extremity DVTs in patients have decreased by over 30% since implementation of the program. They have also seen improved disposition to the right level of care.
"What we have found by having the more aggressive mobility program is we’re not having physical therapists bogged down with doing consults that aren’t medically necessary," Pollart says. "Now they can focus their time on the cases they really need to see. What we’re seeing is a better disposition for the patients when they leave."
Families are also more confident taking patients home from the hospital, and conflict at discharge has decreased, she says.
"When you talk about discharge planning with a family member and the only paradigm they see is [a] loved one is always in bed, they start to get anxious because they think, 'How am I going to be able to care for him or her at home?' " So, we wanted to make sure that we changed that perspective so that when that family came in, they saw patients who were out of bed for meals [or walking]," she says.
Hospital employee injuries have also decreased.
"At the start of the program, our employee-related patient handling injuries were quite high," Pollart says. "They averaged anywhere from on the low end to maybe 9 or 10 a month, and on the high end to maybe 25 to 30 a month."
After going live with a mobility team and investing in patient handling equipment, the hospital reduced employee injuries by over 60%.
"When you look at that just from an employee standpoint, one employee injury is too much," Hansen says, "but when you look at [the] financial standpoint—if you were only looking at the dollars—every workers' compensation claim … averages $20,000 dollars. The investment in that equipment is easily justified by the fewer number of injuries."
Finally, staff engagement and satisfaction has also increased.
Nonclinician mobility team members who help with the program are inspired to follow a career path in healthcare, Pollart says.
"I have a couple that are going to continue to go to school to be therapists. Another one really likes exercise physiology," she says. "So, it’s really helped them shape their future career path."
And hospital staff understands that the organization is committed to creating a safe work environment.
"The fact is that our hospital did recognize [the staff's] priorities and gave them a team and invested in the equipment," Pollart says. "Their perspective about senior leadership understanding the complexities of the work they do has significantly increased because of it. They feel like the organization is committed to their safety."
"Our mission [for the mobility program] is this: prevention of hospital-acquired functional decline and other adverse outcomes to facilitate the earliest and the most independent setting," Pollart says. "Our philosophy was if you walk into the hospital, we want you to walk out."
Here's are the five ways they're achieving that.
1. Make Mobility an Interdisciplinary Project
It was not just the nurses who wanted to improve patient ambulation, other disciplines were on board as well to create a new mobility program.
"With the physical therapists, similarly, we heard they frequently get pulled from doing their clinical consultation because nursing needs an extra pair of hands to get somebody out of bed," Pollart says.
"Likewise, one of my surgeons said, 'You know, Leslie, I write activity orders, but they’re often not carried out consistently, so it’s a mere suggestion, not an order.' That was [a] frustration."
The director of rehabilitation and the IT department became engaged in the project. The IT department helped to integrate newly created assessment tools into the electronic medical record.
Thus, began the creation of a six-person dedicated mobility team.
"Some mobility programs cross-trained patient care assistants," Pollart says. "When I was evaluating that, I worried that someone who already had an established skill set would always feel like they had competing priorities."
Many of the mobility team members were transporters at the hospital.
"We actually hired them for their attitude, their desire to learn a new skill, and their communication," Pollart says.
The therapy department developed competencies to train the new team in safe patient handling.
"They had to go through a rigorous training with the therapy department," she says. "It wasn’t just didactic, it was simulation. Then they went on to seeing patients paired with a therapist. The therapist then signed them off when they felt that [the team was] completely able to be independent."
2. Designate Responsibility
One benefit of the mobility team is that it allows nurses and therapists to work at the top of their licenses.
"It allows the nurses to, for example, medicate a patient for pain in a timely manner rather than to get a patient out of bed. The person that doesn’t need a license to practice can [help ambulate patients] safely," Hansen says.
To achieve this, it was important to clearly delineate each group's responsibility with patient assists.
The mobility team is responsible for maximum assists, and nursing is responsible for independent or minimal assists. Therapists can be involved in a range of assists depending on the acuteness of the mobility issues and whether the patient needed a consultation for appropriate disposition, Pollart says.
"I think that’s what really went to the success of this program," she says. "This wasn’t just adding a team and expecting them to solve all the problems with mobility, but defining those responsibilities according to each job role."
3. Create an Assessment Tool
To clearly define the patient's mobility needs, an assessment tool was created and integrated into the EMR. This allows nurses to delegate mobility responsibilities to the correct practitioner, such as nursing, physical therapy, or the mobility team.
"Based on how [a] patient scores on the tool, that patient’s mobility is assessed to be independent, minimal, moderate, or maximum assist," Pollart says. "We wanted to target the mobility team and [the patients] that often required more man power to ambulate."
The tool is used to assess patients on admission and then at least once per day during the duration of their hospital stay.
Four questions are asked in the assessment:
1. Can the patient lift his or her legs often? If so, is it done independently or with assistance?
2. Can the patient move from a lying to a sitting position independently or with assistance?
3. Can he or she move from sitting to standing independently or with assistance?
4. Can the patient take a step forward?
The tool prompts the practitioner to go to the next question depending on the response.
"Then the mobility team has a work list of all of those patients that score into the mobility team," Pollart says. "We also populate the patient’s activity order."
Additionally, the mobility team has daily huddles with physical therapists and nurse managers to discuss the patient assignments and their mobility needs.
4. Ensure You Have the Right Equipment
In addition to the mobility team and the assessment tool, the organization also invested about $2 million in safe patient-handling equipment such as lifts, as well as education on how to use the equipment.
The assessment tool used to determine a patient's mobility status also tells nurses what the correct handling equipment is for that patient.
"Some of the patients just wouldn’t ambulate for fear of hurting the staff," Pollart says. "Now the nurses can say, 'You don’t have to worry because we have handling equipment that will help us help you get to a standing position.' "
5. Make Ambulation 'Fun'
"Part of the program is to encourage patients, [and] to make ambulation kind of fun and something to look forward to," Pollart says.
Upon admission, all family members are encouraged—unless it’s contrary to treatment—to bring in comfortable shoes for the patient. There are distance markers at certain points in the hospital so that the interdisciplinary team and the patients can track how far they've walked. Mobility journals are provided so patients can fill them out as they accomplish their mobility plans of care.
Patients are also encouraged to walk outside their rooms at least twice a day and to get out of bed for meals, which is known as "Heels for Meals," because the patients have their heels on the floor while eating.