Annals for Hospitalists Inpatient Notes - Bedrest Is ToxicWhy Mobility Matters in the Hospital

For decades, bedrest has been linked to disability. As a 1944 article in JAMA explained, The physician must always consider complete bed rest as a highly un-physiologic and definitely hazardous form of therapy, to be ordered only for specific indications and discontinued as early as possible (1). Since then, a robust literature has demonstrated that bedrest leads to functional decline in hospitalized patients. In particular, those older than 65 years are at substantial risk: Approximately 1 in 3 have functional decline (loss of independence in activities of daily living [ADLs]) after hospitalization (2). More recent studies of wearable mobility sensors have shown that even a limited number of steps during hospitalization can make the difference between functional decline and preserved independence during hospitalization (3). Several studies have suggested a threshold effect of approximately 1000 steps (about 2000 to 2500 feet, depending on stride length, or less than a one-half mile) per day to prevent harm. Unfortunately, most patients rarely leave the bed when hospitalized. In 1 study, inpatients with no activity restrictions wore mobility sensors continuously and were noted to spend, on average, only 45 minutes out of bed per day (4). The authors described this tendency as an unrecognized epidemic. Together, these studies have led us to wonder whether there might be a mobility-toxicity curve. We hypothesize that there is a threshold number of steps that patients must take to avoid functional decline in the hospital. There may also be another threshold, above which patients are unlikely to accrue additional much benefit (Figure 1). Figure 1. Mobility and functional ability at hospital discharge. ADLs = activities of daily living. Considering what we know about mobility and functional decline among hospitalized patients, what can hospitalists do to promote healthy mobility during acute care? First, hospitalists should assess the baseline mobility of all patients at the time of admission, and document it in their admission history and physical examination findings. Hospitalists should ask patients and their caregivers about their current level of functional independence and level of mobility for the 2 to 4 weeks preceding hospitalization. This is important not only to understand the patient's baseline function but also to establish a goal of maintaining that level of mobility throughout the hospitalization. How might a hospitalist better learn about a patient's mobility? First, it is often helpful to consider the nursing assessment of ADLs and mobility. If mobility is not specifically addressed as a stand-alone item in the nursing admission assessment, further information about function might be found in other areas of the chart. For example, the 4-level mobility subcomponent of the Braden Scale (which is used universally to assess risk for pressure ulcers) may provide additional information. These data points do not substitute for the hospitalist's assessment; however, they can add context, increase confidence in the initial assessment, and contribute to a mobility plan. Second, hospitalists should formulate a mobility plan for each patient at the time of admission. Issues of function and mobility should be addressed early in the hospital course, not put off until the time of discharge. Issues of mobility are often given less attention during discharge planning rounds than other aspects of transitional care (such as medications, follow-up testing, and appointments). Some have wondered whether this lack of attention has facilitated the surge in use of skilled-nursing facilities as a discharge destination (5). The mobility plan should outline daily goals for time out of bed and walking. Figure 2 shows a 5-level mobility guide used at the Hospital of the University of Pennsylvania to help patients understand their activity goals, based on baseline functional status, ranging from permanently bed-bound (red box) to fully ambulatory (green box). Hospitalists should write activity orders that encourage the appropriate amount of activity for the patient. Likewise, a hospitalist should never write an order for bedrest unless the patient is permanently disabled (bedbound) at baseline. For all patients whose functional status or mobility is below baseline on admission, we recommend inclusion of functional decline or impaired mobility on the problem list in the daily progress note. Figure 2. Patient mobility guide used at the Hospital of the University of Pennsylvania. Third, hospitalists should discuss the mobility plan with the bedside nurse and the patient as an explicit part of the daily rounds. It may also be helpful to coordinate with others, such as patient care assistants or hospital volunteers, who can assist patients with walking. On a related note, physical and occupational therapy services do not need not be consulted for every patient for this purpose. We recommend reserving these consultations for times when the patient has specific functional deficits that may require skilled rehabilitation (e.g., difficulty or dependency in ADLs). Our clinical experience leads us to believe that the existence of a thoughtful plan to address functional status and mobility during and after hospitalization could help reduce the number of discharges to skilled-nursing facilities, enhance patient engagement and experience, and perhaps even influence postdischarge outcomes of care. Conversely, the lack of a thoughtful mobility plan contributes to functional decline during hospital stays, particularly for older adults. Assessment of functional status and mobility on admission and throughout the hospitalization must become our new norm. It's time for hospitalists to take a leading role in promoting patient mobility in the hospital to neutralize the toxicity of bedrest.