Barriers to mobility during hospitalization from the perspectives of older patients and their nurses and physicians

The Therapeutic Hub: A Person-Centered Approach to Age-Friendly Care

ABSTRACT

Providing age-friendly care to hospitalized older adults is critical to achieving favorable outcomes. The Therapeutic Hub is a space at an acute care level 1 trauma center in which nurses and other staff utilize the 4Ms of an Age-Friendly Health System framework to offer multisensory stimulation and comfort to older patients, with the aim of preventing cognitive and functional decline, agitation, and delirium. Individualized nonpharmacological therapeutic interventions are delivered through relationship-centered care. This article outlines the 4Ms (Mobility, Mentation, Medication, and What Matters), addresses barriers to implementing age-friendly care, and describes the Therapeutic Hub and its positive impact on patient outcomes.

Student-Led Mobility Interventions for Hospitalized Adults: A Mixed-Methods Feasibility and Acceptability Study

BACKGROUND

Inactivity in hospitalized patients often leads to functional decline. We created an undergraduate course to promote mobilization, provide hands-on learning, and address staff shortages.

PURPOSE

To assess the feasibility and acceptability of undergraduate students providing mobility-focused interventions for hospitalized adults.

METHODS

This mixed-methods study was conducted at a level 1 trauma academic center. We analyzed program feasibility and acceptability using quantitative data and thematic analysis of interviews and focus groups.

RESULTS

In total 47 individuals (n = 14 students, n = 9 patients, and n = 24 clinicians) were included. Students averaged 4.1 mobility sessions per 4-hour shift. All stakeholders agreed the program is acceptable, and 98.6% affirmed the program is feasible. The themes identified included positive impacts on patient care, enhanced student professional development, and practical implementation challenges.

CONCLUSIONS

Student-led mobility interventions can be an acceptable strategy to mitigate immobility harm in hospitalized patients. The integration of students enhances patient care and provides valuable educational experiences.

Sepsis Survivors' Functional Recovery and Symptom Experience Following Intensive Care Unit Hospitalization

PURPOSE OF STUDY

The purpose is to describe sepsis survivors' functional recovery and symptom experience following Intensive Care Unit (ICU) hospitalization.

PRIMARY PRACTICE SETTINGS

Academic Medical Center, Community Living.

METHODOLOGY AND SAMPLE

This longitudinal observational study recruited participants during hospitalization at two adult ICUs in a single Midwestern academic medical center. Participants completed surveys to assess function and symptom experience at baseline (discharge), 1-month, 3-months, and 6-months post-discharge.

RESULTS

Participants were non-Hispanic Whites with mean age 55.4 years (SD = 17.0). The majority were discharged to home (78.6%), with 3 (21.4%) discharged to a skilled nursing facility or acute rehabilitation unit. Participants had notable improvements in mobility, self-rated health, and fatigue from discharge to 6-months post-discharge. Increases in mobility from discharge to 1 month, 3 months, and 6 months were statistically significant (α < .05). Decreases in fatigue from discharge to 1 month and 6 months were statistically significant (α < .05). Cognitive and social engagement and other symptom experience measures did not differ significantly during the study period.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

Findings reveal trends in mobility recovery and symptom experience post-hospitalization, which are important considerations post-ICU sepsis hospitalization. This study reinforces the need to promote early mobilization of patients during hospitalization and work with patients to develop strategies for mobility recovery post-hospitalization, as part of a comprehensive plan which integrates a client's medical, behavioral, social, psychological, functional, and other needs. The authors encourage assessment of common symptoms, including pain, fatigue, anxiety, and sleep disturbance, experienced by sepsis survivors during and post-hospitalization. As a result, case managers will be better positioned to implement evidence-based interventions to promote recovery and reduce symptom burden and improve outcomes. Evidence-based interventions should include those that are centered on client's functional and symptom-related needs, preferences, safe mobility, and facilitate awareness of and connections with community supports and resources.

The Optimal Physical Recovery After Hospitalization (OPRAH) intervention to improve physical activity and protein intake after oncological surgery: a feasibility study

PURPOSE

(1) To assess the feasibility of a blended intervention, combining a smartphone app for self-monitoring of physical activity and protein intake with coaching from a physiotherapist and dietician after hospitalization and (2) to evaluate the associated study procedures.

METHODS

A single-arm feasibility study was performed with adult patients scheduled for curative intent gastrointestinal or lung cancer surgery. Patients were provided with a smartphone app and accelerometer one week before surgery, which they used for six weeks following discharge. In addition, patients received coaching from a physiotherapist and dietician. Feasibility was assessed by evaluating participation and completion rates, user adherence, system usability score (SUS), as well as experiences and safety, based on predefined criteria.

RESULTS

In total, 32 patients were included, with participation and completion rates of 69 and 75%, respectively. User adherence to wearing the accelerometer was deemed satisfactory (91%), while user adherence to protein intake was suboptimal (59%). The mean SUS was acceptable (73.5). Patient experiences were predominantly positive, although some patients mentioned a lack of options in the protein registration tool.

CONCLUSION

The intervention is feasible for implementation in a larger study. To improve adherence, modifications are needed regarding self-recording of protein intake. Study procedures require minor modifications.

What Do Nurses Think of Their Role in the Hospital's Restorative Care and Rehabilitation Services for Older Patients?: A Qualitative Systematic Review

AIMS

To examine rehabilitation nurses' perspectives on their roles in caring for older patients in hospitals, emphasising how they fulfil these roles and their significance in geriatric rehabilitation (GR).

BACKGROUND

The need for rehabilitation services was rising with an aging population. Rehabilitation nurses provided evidence-based care to older patients and encouraged them to participate in their rehabilitation goals. Rehabilitation nurses were vital to recovery; their contributions needed to be appreciated and valued.

DESIGN

A qualitative systematic review.

METHODS

A systematic review was conducted using the Joanna Briggs Institute (JBI) methodology for qualitative evidence and a PROSPERO protocol CRD42023435728 published beforehand. From inception to 9 October, 2023, a comprehensive database search was developed using Medline and translated into five databases, including CINAHL, Web of Science, Scopus, ProQuest and Ageline.

RESULTS

Thirty-three studies were reviewed, identifying six key themes, including decision-making, nursing role gaps, care coordination, communication, nursing skills and gender preference.

CONCLUSION

This review examined rehabilitation nurses' experiences working with older patients in rehabilitation services. It highlighted gaps in their recognition and decision-making involvement despite being care coordinators, caregivers and advocates who were undervalued as rehabilitation team members.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

The review highlighted the importance of valuing nurses' contributions and re-evaluating the rehabilitation model.

FURTHER IMPLICATIONS OF THIS STUDY

Interviewing rehabilitation nurses can validate the findings, potentially improving rehabilitation nursing practices for older patients.

REPORTING METHOD

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

NO PATIENT OR PUBLIC CONTRIBUTION

Not applied since it was a systematic review.

"It's Just Really Important for Us All to Be on the Same Page": Qualitative Evaluation of Factors That Influence Written Mobility Communication

OBJECTIVE

Poor interdisciplinary team communication is a known barrier to increasing inpatient mobility. Understanding why and how clinicians from different disciplines communicate about mobility would help inform communication improvements. This qualitative interview study aimed to describe and explore clinician perceptions about written mobility communication and perceived barriers and enablers to this communication.

METHODS

A rapid deductive qualitative approach was used to efficiently capture information for local improvement. Clinicians (physical therapists, nurses, physicians, and occupational therapists) working on 3 internal medicine wards in a metropolitan teaching hospital in Brisbane, Australia were purposefully sampled and invited to participate in individual interviews. Questions were based on the Consolidated Framework for Implementation Research. Interviews were recorded, transcribed, and analyzed using deductive and inductive thematic methods.

RESULTS

From 17 interviews, key themes identified that written communication about patient mobility is important and valued by clinicians; clinicians learn documentation on the job, often from physical therapists; clinicians are not aware of organizational responsibility for mobility communication; multiple purposes for written communication contribute to multiple locations and inconsistency; and clinicians perceive that improvement would require a multidisciplinary and multilevel approach. Suggestions for improvement included the use of a common language, consistent use of existing bedside communication tools, and clearer responsibility for written communication about mobility.

CONCLUSION

Written communication about patient mobility was valued by clinicians, and a range of barriers to effective interdisciplinary communication was identified. Clear professional roles and responsibility for written mobility communication are important. Suggestions for improvement included an interdisciplinary language supported by multidisciplinary education and organizational governance.

IMPACT

Written communication about patient mobility is recognized as critical to safe, high-quality hospital care. Our findings suggest that successful mobility communication improvements must involve multiple disciplines and include clear organizational governance to support staff training, clear role responsibilities, and quality monitoring.

LAY SUMMARY

This study found that staff on a medical ward think writing about mobility is important for patient and staff safety. Having clear roles and responsibilities for writing about mobility is important and consistency may be improved through education and training.

Association between duration of urinary catheterization and post-operative mobilization following elective cesarean section: A retrospective case-control study in Espoo, Finland

INTRODUCTION

Cesarean section is the most common surgery performed on women. The enhanced recovery recommendations are early urinary catheter removal and early mobilization, as essential elements of post-operative care. This study aimed to analyze the association between these elements and whether limiting the catheter treatment duration affects the timing of post-operative mobilization.

METHODS

This retrospective case-control study compared the mobilization of healthy elective cesarean patients under different instructions on urinary catheter removal: cases with a preset catheter removal time (8-12 hours) and controls with catheter removal based on midwife considerations. Apart from the preset time of catheter removal, the routine post-operative care was given by the same personnel without any advice on patient mobilization. Data on patient demographics, surgery details, post-operative medication, first upright mobilization, the length of hospital stay, and patient satisfaction were analyzed.

RESULTS

The study comprised 52 cases and one control for each case (N=104). The mean duration of urinary catheterization was 20.15 ± 6.59 and 11.30 ± 4.20 hours in the control and intervention groups, respectively (p<0.001). A linear regression analysis showed a significant association between the catheter removal time and patient mobilization, when adjusted for maternal background parameters (age, BMI, fear of childbirth diagnosis, prior uterine scar), duration and timing of the surgery, bleeding and post-operative analgesic use (R2=0.444, p<0.001). No difference was detected in the length of hospital stay, or patient satisfaction.

CONCLUSIONS

Limiting the duration of urinary catheter therapy is associated with shorter time to post-operative mobilization. A prospective randomized trial would provide more detailed information.

Physiotherapy in acute geriatrics wards: What (de)motivates patients? A qualitative study based on self-determination theory

BACKGROUND

While the benefits of physiotherapy for hospitalized older patients (HOPs) are well established, these patients are often considered demotivated by healthcare team members (HTMs), which is perceived as a hindrance to their rehabilitation. The quantitative data currently available on the lack of involvement of HOPs are mainly measures of mobility. Motivation as such has, to our knowledge, never been measured. Therefore, this study aims to quantify for the first time the motivation levels of HOPs in their participation in activities of daily living (ADLs) and physiotherapy, and to explore the motivating factors behind their participation in physiotherapy.

METHODS

The motivation of 60 older patients hospitalized in an acute geriatrics ward was quantified using the Scale of Demotivation Assessment (SDA). Out of these participants, 14 were interrogated through individual semi-structured face-to-face interviews. After transcription, data were analyzed according to Self-Determination Theory, which has been proven effective in the understanding of motivational mechanisms.

RESULTS

The prevalence of demotivation was 47% (95% CI: [0.34;0.6]) for ADLs and 35% (95% CI: [0.23;0.48]) for physiotherapy. The main demotivating factors were the feeling of external control (lack of autonomy) and dependance experienced by HOPs, as well as the limited availability of staff during hospitalization. Conversely, feelings of competence, security, respect for limits, and commitment from the HTMs were important motivating factors.

CONCLUSION

A large number of relational factors have an impact on the motivation of HOPs regarding their participation in ADLs and in physiotherapy sessions. Appropriate time and space organizing and the provision of suitable equipment, combined with a genuine caring and respectful attitude from the HTMs, could considerably encourage the expression of intrinsic motivation and thus the involvement of HOPs in their own care program.

Factors impeding physical activity in older hospitalised patients: A qualitative meta-synthesis

BACKGROUND

Older hospitalised patients have low levels of physical activity and multiple impairing factors.

AIMS

To systematically evaluate the perceived barriers to physical activity among older patients during hospitalisation, and provide reference for future intervention programs.

DESIGN

Following ENTREQ, do a systematic evaluation and synthesis of qualitative investigations.

METHODS

An exhaustive exploration was conducted across the CNKI, Wanfang Database, VIP Database, China Biomedical Literature Database, PubMed, Embase, Cochrane Library and Web of Science from their inception until August, 2023 to identify qualitative research on obstacles to physical activity among older hospital patients. The quality of the literature was evaluated using the Joanna Briggs Institute's critical appraisal tool for qualitative research. Meta-synthesis method was used to integrate the results.

RESULTS

In total, 8 literatures were included, 43 themes were extracted, and analogous research results were amalgamated to generate 10 categories and 3 syntheses: individual level, interpersonal influencing factors and hospital environment and resources level.

CONCLUSION

Older inpatients are faced with multiple barriers to physical activity. Medical staff should pay attention to changes in physical activity during hospitalisation, identify barriers to physical activity in older inpatients and provide references for promoting physical activity programs for the older.

NO PATIENT OR PUBLIC CONTRIBUTION

This study is a meta-synthesis and does not require relevant contributions from patients or the public.

WHAT IS ALREADY KNOWN

Older patients are at low physical activity levels during hospitalisation. Older inpatients are faced with multiple barriers to physical activity.

WHAT THIS PAPER ADDS

Factors of physical activity impairment in hospitalised older patients should be considered in the context of health status, psychological factors, motivation and social support. Disease-induced psychological fallout has a greater impact on physical activity in the older.

Nursing care for hospitalized older adults - fall accidents versus safe mobility: a scoping review

OBJECTIVES

to map the constituent elements of the safe mobility concept present in hospital care for older adults.

METHODS

a scoping review of 35 articles searched in databases and gray literature - BDENF/VHL, Scopus, CINAHL/EBSCO, Embase, Web of Science, PEDro, MEDLINE/PubMed and CAPES Theses and Dissertations Catalog. No time or language cut-off was established.

RESULTS

none of the studies presented a clear safe mobility concept, however its constituent elements involve factors related to patient (behavioral factors, conditions, diseases, signs and symptoms, nutritional status, age, balance, strength, gait quality, sleep), the institution (environment, treatment devices, guidelines, medications and polypharmacy, material and human resources and clothing/shoes) and the nature of the interventions (related to the patient, institution and family).

FINAL CONSIDERATIONS

the constituent elements of safe mobility express hospital units' capacity to guarantee care and protection from fall accidents for hospitalized older adults.

Enhancing team communication to improve implementation of a supervised walking program for hospitalized veterans: Evidence from a multi-site trial in the Veterans Health Administration

INTRODUCTION

The timely translation of evidence-based programs into real-world clinical settings is a persistent challenge due to complexities related to organizational context and team function, particularly in inpatient settings. Strategies are needed to promote quality improvement efforts and implementation of new clinical programs.

OBJECTIVE

This study examines the role of CONNECT, a complexity science-based implementation intervention to promote team readiness, for enhancing implementation of the 'Assisted Early Mobility for Hospitalized Older Veterans' program (STRIDE), an inpatient, supervised walking program.

DESIGN

We conducted a stepped-wedge cluster randomized trial using a convergent mixed-methods design. Within each randomly assigned stepped-wedge sequence, Veterans Affairs Medical Centers (VAMCs) were randomized to receive standardized implementation support only or additional training via the CONNECT intervention. Data for the study were obtained from hospital administrative and electronic health records, surveys, and semi-structured interviews with clinicians before and after implementation of STRIDE.

SETTING

Eight U.S. VAMCs.

PARTICIPANTS

Three hundred fifty-three survey participants before STRIDE implementation and 294 surveys after STRIDE implementation. Ninety-two interview participants.

INTERVENTION

CONNECT, a complexity-science-based intervention to improve team function.

MAIN OUTCOME MEASURES

The implementation outcomes included STRIDE reach and fidelity. Secondary outcomes included validated measures of team function (i.e., team communication, coordination, role clarity).

RESULTS

At four VAMCs randomized to CONNECT, reach was higher (mean 12.4% vs. 3.8%), and fidelity was similar to four non-CONNECT VAMCs. VAMC STRIDE delivery teams receiving CONNECT reported improvements in team function domains, similar to non-CONNECT VAMCs. Qualitative findings highlight CONNECT's impact and the influence of team characteristics and contextual factors, including team cohesion, leadership support, and role clarity, on reach and fidelity.

CONCLUSION

CONNECT may promote greater reach of STRIDE, but improvement in team function among CONNECT VAMCs was similar to improvement among non-CONNECT VAMCs. Qualitative findings suggest that CONNECT may improve team function and implementation outcomes but may not be sufficient to overcome structural barriers related to implementation capacity.

Implementation of MOVIN by a Nurse-Led Clinical Team: A Multiple Methods Evaluation Using the RE-AIM Framework

PURPOSE

To evaluate the implementation of MOVIN, a multicomponent mobility intervention, by a nurse-led team and measure the effectiveness on unit-level outcomes.

METHOD

A pragmatic quasi-experimental study was conducted on an inpatient adult medical unit. Evaluation was guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Interviews with 13 organizational partners were conducted to understand barriers and facilitators to adoption. Thematic analysis was used to analyze the data. Quantitative data to determine effectiveness on distance of patient ambulation and percent of patients ambulated by nursing staff were analyzed using an interrupted time series.

RESULTS

A significant increase in total weekly distances for patient ambulation and percent of patients ambulated by nursing staff occurred between preintervention, intervention, and postintervention periods. Themes for adoption included: Value, Immediate Feedback, Inclusive Implementation, Resource Needs, and Lack of Organizational Evidence. The nurse-led team demonstrated high fidelity to maintaining the core components of MOVIN.

CONCLUSION

A nurse-led team can successfully launch a multicomponent mobility intervention and sustain impact. RE-AIM supported assessments of key partners at multiple organizational levels, capturing critical unit level outcomes. Multiple methods for data collection and analysis yielded rich results to inform future dissemination of MOVIN. [Research in Gerontological Nursing, 17(4), 189-201.].

[eHealth applications for promotion of physical activity after visceral surgery : A systematic review]

BACKGROUND

eHealth applications can support early mobilization and physical activity (PA) after surgery. This systematic review provides an overview of eHealth services to enhance or record PA after visceral surgery interventions.

METHODS

Two electronic databases (MEDLINE PubMed and Web of Science) were systematically searched (November 2023). Articles were considered eligible if they were controlled trials and described digital devices used to promote PA after visceral surgery. The Cochrane risk of bias (RoB-2) tool was used to determine the methodological quality of studies.

RESULTS

A total of nine randomized controlled studies (RCT) were included in this systematic review. The studies differed with respect to the interventions, surgical indications and evaluation variables. The risk of bias of the individual studies was moderate. The six studies using activity trackers (AT) predominantly showed insignificant improvements in the postoperative step count. The more complex fitness applications could partially reveal significant advantages compared to the control groups and the home-based online training also showed a significant increase in functional capacity.

CONCLUSION

Activity tracking alone has so far failed to show clinically relevant effects. In contrast, the more complex eHealth applications revealed advantages compared to usual postoperative care. More high-quality studies are needed for evidence-based recommendations for eHealth services in conjunction with visceral surgery.

The rate of disuse osteopenia in admitted, non-weight-bearing patients

Disuse osteopenia is a well-recognized consequence of prolonged physical inactivity, but its rate after orthopaedic injuries necessitating non-weight-bearing is not well studied. The purpose of this study was to estimate the rate of disuse osteopenia at the lumbar spine and proximal femur in patients with lower extremity trauma admitted to the hospital. We performed a retrospective chart review of patients with lower extremity trauma with a period of strict non-weight-bearing between completion of two computed tomography (CT) scans. The radiodensity of the proximal femur or lumbar vertebrae was measured from the earliest and latest available CT scans within the non-weight-bearing timeframe. The change in estimated bone mineral density (eBMD) was calculated as a proxy for disuse osteopenia. A total of 189,111 patients were screened, with 17 patients in the proximal femur group and 15 patients in the lumbar spine group meeting inclusion and exclusion criteria. The average rate of change in eBMD of the proximal femur was a decrease of 7.54 HU/day, 95% confidence interval (CI) [3.65, 11.43]. The average rate of change in eBMD of the lumbar spine was an increase of 1.45 HU/day, 95% CI [-3.15, 6.06]. In admitted, non-weight-bearing orthopaedic trauma patients, our novel study suggests that the proximal femur experiences disuse osteopenia during periods of non-weight-bearing, although this finding was not observed at the lumbar spine. The clinical significance of this data underscores the important consideration of disuse osteopenia by all physicians when caring for patients that may require non-weight-bearing restrictions.

Mobility level and factors affecting mobility status in hospitalized patients admitted in single-occupancy patient rooms

BACKGROUND

Although stimulating patients' mobility is considered a component of fundamental nursing care, approximately 35% of hospitalized patients experience functional decline during or after hospital admission. The aim of this study is to assess mobility level and to identify factors affecting mobility status in hospitalized patients admitted in single-occupancy patient rooms (SPRs) on general wards.

METHODS

Mobility level was quantified with the Johns Hopkins Highest Level of Mobility Scale (JH-HLM) and EQ-5D-3L. GENEActiv accelerometer data over 24 h were collected in a subset of patients. Data were analyzed using generalized ordinal logistic regression analysis. The STROBE reporting checklist was applied.

RESULTS

Wearing pajamas during daytime, having pain, admission in an isolation room, and wearing three or more medical equipment were negatively associated with mobilization level. More than half of patients (58.9%) who were able to mobilize according to the EQ-5D-3L did not achieve the highest possible level of mobility according to the JH-HLM. The subset of patients that wore an accelerometer spent most of the day in sedentary behavior (median 88.1%, IQR 85.9-93.6). The median total daily step count was 1326 (range 22-5362).

CONCLUSION

We found that the majority of participating hospitalized patients staying in single-occupancy patient rooms were able to mobilize. It appeared, however, that most of the patients who are physically capable of walking, do not reach the highest possible level of mobility according to the JH-HLM scale. Nurses should take their responsibility to ensure that patients achieve the highest possible level of mobility.

Inpatient physical activity across a large university city hospital: a behavioral mapping study

BACKGROUND

Physical inactivity is common during hospitalization. Physical activity has been described in different inpatient populations but never across a hospital.

PURPOSE

To describe inpatient movement behavior and associated factors throughout a single university hospital.

METHODS

A prospective observational study was performed. Patients admitted to clinical wards were included. Behavioral mapping was undertaken for each participant between 9AM and 4PM. The location, physical activity, daily activity, and company of participants were described. Barriers to physical activity were examined using linear regression analyses.

RESULTS

In total, 345 participants from 19 different wards were included. The mean (SD) age was 61 (16) years and 57% of participants were male. In total, 65% of participants were able to walk independently. On average participants spent 86% of observed time in their room and 10% of their time moving. A physiotherapist or occupational therapist was present during 1% of the time, nursing staff and family were present 11% and 13%, respectively. Multivariate regression analysis showed the presence of an intravenous line (p = .039), urinary catheter (p = .031), being female (p = .034), or being dependent on others for walking (p = .016) to be positively associated with the time spent in bed. Age > 65, undergoing surgery, receiving encouragement by a nurse or physician, reporting a physical complaint or pain were not associated with the time spent in bed (P > .05).

CONCLUSION

As family members and nursing staff spend more time with patients than physiotherapists or occupational therapists, increasing their involvement might be an important next step in the promotion of physical activity.

Barriers and facilitators for physical activity on acute geriatric and rehabilitation wards: a survey study

OBJECTIVES

During hospitalisation, physical inactivity is common among older patients and is associated with adverse outcomes, e.g. functional decline. This study identified barriers and facilitators of physical activity with geriatric patients during hospital admission.

METHODS

This is a cross-sectional descriptive study, on two acute geriatric units and one rehabilitation unit, using a researcher-administered survey methodology in patients 70 years or older. A new questionnaire was developed based on a literature review, and was administered bedside and face-to-face with the older patients.

RESULTS

72 patients, mean age 83.6 years, completed the questionnaire. 88.9% of the participants found physical activity important during hospitalisation. The main patient-related determinants were fear of falling and symptoms of current illness (e.g. pain). The main environmental-related determinants were the presence of medical devices, and the availability of walking aids. Half of the patients felt motivated by the hospital staff, and one out of six participants felt discouraged. Receiving more assistance for walking and having access to other types of physical activity was expected to increase physical activity. Additionally, motivation from family would be a facilitator for 44.4% of the participants.

CONCLUSION

Promoting physical activity on acute geriatric units will require interventions at different levels. Most importantly, focusing on interpersonal motivators and positive reinforcement by hospital staff could be beneficial strategies to increase the physical activity of older hospitalised patients.

The efficacy of a blended intervention to improve physical activity and protein intake for optimal physical recovery after oncological gastrointestinal and lung cancer surgery, the Optimal Physical Recovery After Hospitalization (OPRAH) trial: study protocol for a randomized controlled multicenter trial

BACKGROUND

Improving physical activity, especially in combination with optimizing protein intake, after surgery has a potential positive effect on recovery of physical functioning in patients after gastrointestinal and lung cancer surgery. The aim of this randomized controlled trial is to evaluate the efficacy of a blended intervention to improve physical activity and protein intake after hospital discharge on recovery of physical functioning in these patients.

METHODS

In this multicenter single-blinded randomized controlled trial, 161 adult patients scheduled for elective gastrointestinal or lung cancer surgery will be randomly assigned to the intervention or control group. The purpose of the Optimal Physical Recovery After Hospitalization (OPRAH) intervention is to encourage self-management of patients in their functional recovery, by using a smartphone application and corresponding accelerometer in combination with coaching by a physiotherapist and dietician during three months after hospital discharge. Study outcomes will be measured prior to surgery (baseline) and one, four, eight, and twelve weeks and six months after hospital discharge. The primary outcome is recovery in physical functioning six months after surgery, and the most important secondary outcome is physical activity. Other outcomes include lean body mass, muscle mass, protein intake, symptoms, physical performance, self-reported limitations in activities and participation, self-efficacy, hospital readmissions and adverse events.

DISCUSSION

The results of this study will demonstrate whether a blended intervention to support patients increasing their level of physical activity and protein intake after hospital discharge improves recovery in physical functioning in patients after gastrointestinal and lung cancer surgery.

TRIAL REGISTRATION

The trial has been registered at the International Clinical Trials Registry Platform at 14-10-2021 with registration number NL9793. Trial registration data are presented in Table 1.

Perspectives of health professionals on physical activity and sedentary behaviour in hospitalised adults: A systematic review and thematic synthesis

OBJECTIVE

To explore health professionals' perspectives on physical activity and sedentary behaviour of hospitalised adults to understand factors that contribute to these behaviours in this environment.

DATA SOURCES

Five databases (PubMed, MEDLINE, Embase, PsycINFO and CINAHL) were searched in March 2023.

REVIEW METHODS

Thematic synthesis. Included studies explored perspectives of health professionals on the physical activity and/or sedentary behaviour of hospitalised adults using qualitative methods. Study eligibility was assessed independently by two reviewers and results thematically analysed. Quality was assessed using the McMaster Critical Review Form and confidence in findings assessed using GRADE-CERQual.

RESULTS

Findings from 40 studies explored perspectives of over 1408 health professionals from 12 health disciplines. The central theme identified was that physical activity is not a priority in this setting due to the complex interplay of multilevel influences present in the interdisciplinary inpatient landscape. Subthemes, the hospital is a place for rest, there are not enough resources to make movement a priority, everyone's job is no one's job and policy and leadership drives priorities, supported the central theme. Quality of included studies was variable; critical appraisal scores ranged from 36% to 95% on a modified scoring system. Confidence in findings was moderate to high.

CONCLUSION

Physical activity in the inpatient setting is not a priority, even in rehabilitation units where optimising function is the key. A shift in focus towards functional recovery and returning home may promote a positive movement culture that is supported by appropriate resources, leadership, policy, and the interdisciplinary team.

More than medications: a patient-centered assessment of Parkinson's disease care needs during hospitalization

Background

Parkinson's disease (PD) increases the risk of hospitalization and complications while in the hospital. Patient-centered care emphasizes active participation of patients in decision-making and has been found to improve satisfaction with care. Engaging in discussion and capturing hospitalization experience of a person with PD (PwP) and their family care partner (CP) is a critical step toward the development of quality improvement initiatives tailored to the unique hospitalization needs of PD population.

Objectives

This qualitative study aimed to identify the challenges and opportunities for PD patient-centered care in hospital setting.

Methods

Focus groups were held with PwPs and CPs to capture first-hand perspectives and generate consensus themes on PD care during hospitalization. A semi-structured guide for focus group discussions included questions about inpatient experiences and interactions with the health system and the clinical team. The data were analyzed using inductive thematic analysis.

Results

A total of 12 PwPs and 13 CPs participated in seven focus groups. Participants were 52% female and 28% non-white; 84% discussed unplanned hospitalizations. This paper focuses on two specific categories that emerged from the data analysis. The first category explored the impact of PD diagnosis on the hospital experience, specifically during planned and unplanned hospitalizations. The second category delves into the unique needs of PwPs and CPs during hospitalization, which included the importance of proper PD medication management, the need for improved hospital ambulation protocols, and the creation of disability informed hospital environment specific for PD.

Conclusion

PD diagnosis impacts the care experience, regardless of the reason for hospitalization. While provision of PD medications was a challenge during hospitalization, participants also desired flexibility in ambulation protocols and an environment that accommodated their disability. These findings highlight the importance of integrating the perspectives of PwPs and CPs when targeting patient-centered interventions to improve hospital experiences and outcomes.

Interrupting bedtime to reverse frailty levels in acute care: a study protocol for the Breaking Bad Rest randomized controlled trial

BACKGROUND

Hospitalized older patients spend most of the waking hours in bed, even if they can walk independently. Excessive bedrest contributes to the development of frailty and worse hospital outcomes. We describe the study protocol for the Breaking Bad Rest Study, a randomized clinical trial aimed to promoting more movement in acute care using a novel device-based approach that could mitigate the impact of too much bedrest on frailty.

METHODS

Fifty patients in a geriatric unit will be randomized into an intervention or usual care control group. Both groups will be equipped with an activPAL (a measure of posture) and StepWatch (a measure of step counts) to wear throughout their entire hospital stay to capture their physical activity levels and posture. Frailty will be assessed via a multi-item questionnaire assessing health deficits at admission, weekly for the first month, then monthly thereafter, and at 1-month post-discharge. Secondary measures including geriatric assessments, cognitive function, falls, and hospital re-admissions will be assessed. Mixed models for repeated measures will determine whether daily activity differed between groups, changed over the course of their hospital stay, and impacted frailty levels.

DISCUSSION

This randomized clinical trial will add to the evidence base on addressing frailty in older adults in acute care settings through a devices-based movement intervention. The findings of this trial may inform guidelines for limiting time spent sedentary or in bed during a patient's stay in geriatric units, with the intention of scaling up this study model to other acute care sites if successful.

TRIAL REGISTRATION

The protocol has been registered at clinicaltrials.gov (identifier: NCT03682523).

'Life is about movement-everything that is alive moves': a mixed methods study to understand barriers and enablers to inpatient mobility from the older patient's perspective

BACKGROUND

Mobility in hospital is important to maintain independence and prevent complications. Our multi-centre study aimed to measure mobility and identify barriers and enablers to mobility participation from the older patient's perspective.

METHODS

Mixed methods study including direct observation of adult inpatients on 20 acute care wards in 12 hospitals and semi-structured interviews with adults aged 65 years or older on each of these wards. Interviews were undertaken by trained staff during the inpatient stay. Quantitative data were analysed descriptively. Qualitative data were initially coded deductively using the theoretical domains framework (TDF), with an inductive approach then used to frame belief statements.

RESULTS

Of 10,178 daytime observations of 503 adult inpatients only 7% of time was spent walking or standing. Two hundred older patient interviews were analysed. Most (85%) patients agreed that mobilising in hospital was very important. Twenty-three belief statements were created across the eight most common TDF domains. Older inpatients recognised mobility benefits and were self-motivated to mobilise in hospital, driven by goals of maintaining or recovering strength and health and returning home. However, they struggled with managing pain, other symptoms and new or pre-existing disability in a rushed, cluttered environment where they did not wish to trouble busy staff. Mobility equipment, meaningful walking destinations and individualised programmes and goals made mobilising easier, but patients also needed permission, encouragement and timely assistance.

CONCLUSION

Inpatient mobility was low. Older acute care inpatients frequently faced a physical and/or social environment which did not support their individual capabilities.

Factors Associated With Function-Focused Care Among Hospitalized Older Adults With Dementia

BACKGROUND

Function-focused care is an approach used to increase physical activity in hospitalized older adults with dementia.

OBJECTIVE

To explore factors associated with participation in function-focused care in this patient population.

METHODS

This was a cross-sectional descriptive study using baseline data from the first 294 participants in an ongoing study on testing function-focused care for acute care using the evidence integration triangle. Structural equation modeling was used for model testing.

RESULTS

The mean (SD) age of the study participants was 83.2 (8.0) years, and the majority were women (64%) and White (69%). Sixteen of the 29 hypothesized paths were significant and explained 25% of the variance in participation in function-focused care. Cognition, quality of care interactions, behavioral and psychological symptoms associated with dementia, physical resilience, comorbidities, tethers, and pain were all indirectly associated with function-focused care through function and/or pain. Tethers, function, and quality of care interactions were all directly associated with function-focused care. The χ2/df was 47.7/7, the normed fit index was 0.88, and the root mean square error of approximation was 0.14.

CONCLUSION

For hospitalized patients with dementia, the focus of care should be on treating pain and behavioral symptoms, reducing the use of tethers, and improving the quality of care interactions in order to optimize physical resilience, function, and participation in function-focused care.

Ambulatory Behavior Assessment Using Deep Learning

This work leverages a custom implementation of a deep neural network-based object detection algorithm to detect people and a set of assistive devices relevant to clinical environments. The object detections form the basis for the quantification of different ambulatory activities and related behaviors. Using features extracted from detected people and objects as input to machine learning models, we quantify how a person ambulates and the mode of ambulation being used.Clinical relevance- This system provides the data required for clinicians and hospitalized patients to work together in the creation, monitoring, and adjustment of ambulatory goals.

Revealing the tension: The relationship between high fall risk categorization and low patient mobility

BACKGROUND

Using an inpatient fall risk assessment tool helps categorize patients into risk groups which can then be targeted with fall prevention strategies. While potentially important in preventing patient injury, fall risk assessment may unintentionally lead to reduced mobility among hospitalized patients. Here we examined the relationship between fall risk assessment and ambulatory status among hospitalized patients.

METHODS

We conducted a retrospective cohort study of consecutively admitted adult patients (n = 48,271) to a quaternary urban hospital that provides care for patients of broad socioeconomic and demographic backgrounds. Non-ambulatory status, the primary outcome, was defined as a median Johns Hopkins Highest Level of Mobility <6 (i.e., patient walks less than 10 steps) throughout hospitalization. The primary exposure variable was the Johns Hopkins Fall Risk Assessment Tool (JHFRAT) category (Low, Moderate, High). The capacity to ambulate was assessed using the Activity Measure for Post-Acute Care (AM-PAC). Multivariable regression analysis controlled for clinical demographics, JHFRAT items, AM-PAC, comorbidity count, and length of stay.

RESULTS

8% of patients at low risk for falls were non-ambulatory, compared to 25% and 54% of patients at moderate and high risk for falls, respectively. Patients categorized as high risk and moderate risk for falls were 4.6 (95% CI: 3.9-5.5) and 2.6 (95% CI: 2.4-2.9) times more likely to be non-ambulatory compared to patients categorized as low risk, respectively. For patients with high ambulatory potential (AM-PAC 18-24), those categorized as high risk for falls were 4.3 (95% CI: 3.5-5.3) times more likely to be non-ambulatory compared to patients categorized as low risk.

CONCLUSIONS

Patients categorized into higher fall risk groups had decreased mobility throughout their hospitalization, even when they had the functional capacity to ambulate.

Hospital-associated disability due to avoidable hospitalizations among older adults

BACKGROUND

Hospital-associated disability (HAD) is a common complication during the course of acute care hospitalizations in older adults. Many admissions are for ambulatory care sensitive conditions (ACSCs), considered potentially avoidable hospitalizations-conditions that might be treated in outpatient settings to prevent hospitalization and HAD. We compared the incidence of HAD between older adults hospitalized for ACSCs versus those hospitalized for other diagnoses.

METHODS

We conducted a retrospective cohort study in inpatient (non-ICU) medical and surgical units of a large southeastern regional academic medical center. Participants were 38,960 older adults ≥ 65 years of age admitted from January 1, 2015, to December 31, 2019. The primary outcome was HAD, defined as decline on the Katz Activities of Daily Living (ADL) scale from hospital admission to discharge. We used generalized linear mixed models to examine differences in HAD between hospitalizations with a primary diagnosis for an ACSC using standard definitions versus primary diagnosis for other conditions, adjusting for covariates and repeated observations for individuals with multiple hospitalizations.

RESULTS

We found that 10% of older adults were admitted for an ACSC, with rates of HAD in those admitted for ACSCs lower than those admitted for other conditions (16% vs. 20.7%, p < 0.001). Age, comorbidity, admission functional status, and admission cognitive impairment were significant predictors for development of HAD. ACSC admissions to medical and medical/surgical services had lower odds of HAD compared with admissions for other conditions, with no significant differences between ACSC and non-ACSC admissions to surgical services.

CONCLUSIONS

Rates of HAD among older adults hospitalized for ACSCs are substantial, though lower than rates of HAD with hospitalization for other conditions, reflecting that acute care hospitalization is not a benign event in this population. Treatment of ACSCs in the outpatient setting could be an important component of efforts to reduce HAD.

Delirium Mediates Incidence of Hospital-Associated Disability Among Older Adults

OBJECTIVE

To examine whether delirium predicts occurrence of hospital-associated disability (HAD), or functional decline after admission, among hospitalized older adults.

DESIGN

Retrospective cross-sectional study.

SETTING AND PARTICIPANTS

General inpatient (non-ICU) units of a large regional Southeastern US academic medical center, involving 33,111 older adults ≥65 years of age admitted from January 1, 2015, to December 31, 2019.

METHODS

Delirium was defined as a score ≥2 on the Nursing Delirium Screening Scale (NuDESC) during hospital admission. HAD was defined as a decline on the Katz Activities of Daily Living (ADL) scale from hospital admission to discharge. Generalized linear mixed models were used to examine the association between delirium and HAD, adjusting for covariates and repeated observations with multiple admissions. We performed multivariate and mediation analyses to examine strength and direction of association between delirium and HAD.

RESULTS

One-fifth (21.6%) of older adults developed HAD during hospitalization and experienced higher delirium rates compared to those not developing HAD (24.3% vs 14.3%, P < .001). Age, presence of delirium, Elixhauser Comorbidity Score, admission cognitive status, admission ADL function, and length of stay were associated (all P < .001) with incident HAD. Mediational analyses found 46.7% of the effect of dementia and 16.7% of the effect of comorbidity was due to delirium (P < .001).

CONCLUSIONS AND IMPLICATIONS

Delirium significantly increased the likelihood of HAD within a multivariate predictor model that included comorbidity, demographics, and length of stay. For dementia and comorbidity, mediation analysis showed a significant portion of their effect attributable to delirium. Overall, these findings suggest that reducing delirium rates may diminish HAD rates.

Indirect Nutrition and Mobility Risks during Hospitalization: An Architectural Perspective on the nutritionDay Study Findings

Nutrition and mobility risks include complex and interrelated physiological, medical, and social factors. A growing body of evidence demonstrates that the built environment can affect patients' well-being and recovery. Nevertheless, the relationship between the built environment, nutrition, and mobility in general hospitals is largely unexplored. This study examines the implications of the nutritionDay study's results for the architectural design of hospital wards and nutrition environments. This one-day annual cross-sectional study uses online questionnaires in 31 different languages to collect ward-specific and patient-specific variables. The main findings relevant to the design of hospital wards were: (1) 61.5% of patients (n = 48,700) could walk before hospitalization and (2) this number dropped to 56.8% on nutritionDay (p < 0.0001), while the number of bedridden patients increased from 6.5% to 11.5% (p < 0.0001), (3) patients who needed more assistance had a much longer mean LOS than mobile patients, (4) mobility was associated with changes in eating, and (5) 72% of units (n = 2793) offered additional meals or snacks, but only 30% promoted a positive eating environment. The built environment may indirectly affect hospitalized patients' mobility, independence, and nutritional intake. Possible future study directions are suggested to further investigate this relationship.

Shared and distinct factors underlying in-hospital mobility of older adults in Israel and Denmark (97/100)

BACKGROUND

Low in-hospital mobility is widely acknowledged as a major risk factor in acquiring hospital-associated disabilities. Various predictors of in-hospital low mobility have been suggested, among them older age, disabling admission diagnosis, poor cognitive and physical functioning, and pre-hospitalization mobility. However, the universalism of the phenomena is not well studied, as similar risk factors to low in-hospital mobility have not been tested.

METHODS

The study was a secondary analysis of data on in-hospital mobility that investigated the relationship between in-hospital mobility and a set of similar risk factors in independently mobile prior to hospitalization older adults, hospitalized in acute care settings in Israel (N = 206) and Denmark (N = 113). In Israel, mobility was measured via ActiGraph GT9X and in Denmark by ActivPal3 for up to seven hospital days.

RESULTS

Parallel multivariate analyses revealed that a higher level of community mobility prior to hospitalization and higher mobility ability status on admission were common predictors of a higher number of in-hospital steps, whereas the longer length of hospital stay was significantly correlated with a lower number of steps in both samples. The risk of malnutrition on admission was associated with a lower number of steps, but only in the Israeli sample.

CONCLUSIONS

Despite different assessment methods, older adults' low in-hospital mobility has similar risk factors in Israel and Denmark. Pre-hospitalization and admission mobility ability are robust and constant risk factors across the two studies. This information can encourage the development of both international standard risk evaluations and tailored country-based approaches.

Exploring the perspectives of clinicians on solutions to tackling physical inactivity and sedentary behaviour in older hospital patients

OBJECTIVE

Despite growing research on sedentary behaviour and physical activity among hospitalised older people, there is little evidence of effective intervention strategies. This study sought input from clinical staff from various health professions on strategies to increase physical activity and reduce sedentariness for hospitalised older people.

METHODS

A 60-minute focus group discussion involving two physiotherapists, two occupational therapists, one doctor, one nurse and one social worker was conducted. Participants were recruited from a subacute geriatric ward and an acute orthopaedic ward with an orthogeriatric service at a general hospital. Data were thematically analysed.

RESULTS

Six strategies to reduce sedentary behaviour and increase physical activity were identified: clear and positive communication for patients and family/carers; educating patients and family/carers; involving family/carers and volunteers; setting physical activity goals; utilising group activities and activities of daily living (ADL); and making the hospital environment activity-friendly.

CONCLUSIONS

This research has revealed novel strategies to increase physical activity and reduce sedentary behaviour in hospital. The next step is to design interventions for testing.

Impact of early urinary catheter removal on successful voiding and physical function in stroke patients

OBJECTIVE

The aim of the present study was to identify factors related to the success of trial without catheter (TWOC) in patients with stroke and to examine the effect of the timing of urinary catheter removal on the course of stroke.

METHODS

Patients who were admitted to the Stroke Care Unit of our institution between March 2018 and October 2021 were included. To identify factors related to success of TWOC, a multivariate analysis was performed on the patient's condition at admission and catheter indwelling time. The patients were divided into two groups by the timing of catheter removal, and we assessed the relationship between the timing of catheter removal successful TWOC and recovery of physical function.

RESULTS

A total of 118 patients were included. The presence of comorbidities and scores of severity and function at admission were not predictors of successful voiding. The time to achieve voiding sussess was significantly shorter in the early catheter removal group than in the later group (p<0.005). Interestingly, the early group also showed better improvements in physical function.

CONCLUSION

Early removal of catheters may lead to early recovery of bladder function, improvement of physical function, and lower risk of complications in patients with stroke. J. Med. Invest. 70 : 436-442, August, 2023.

Steps parameters of elderly patients hospitalised for an acute medical illness in a Swiss University Hospital: a monocentric observational pilot-study

BACKGROUND

Objective mobility goals for elderly hospitalised medical patients remain debated. We therefore studied steps parameters of elderly patients hospitalised for an acute illness, to determine goals for future interventional trials and medical practice.

METHODS

Observational study conducted from February to November 2018 in a medical ward of the Lausanne University Hospital, Switzerland. We measured the step parameters of consecutive medical patients aged ≥65 years admitted for an acute medical illness using a wrist accelerometer (Geneactiv). We also collected demographic, somatic and functional factors.

RESULTS

Overall, 187 inpatients had their step parameters (daily step count, walking cadence and bout duration) measured with accelerometers worn for a mean of 3.6 days (standard deviation [SD] 3.2). Elderly inpatients (81.5 years, SD 8.5) walked a median of 603 steps daily (interquartile range [IQR] 456-809), at a median cadence of 100 steps/minute (IQR 99-101) with median walking bouts of 33 seconds (IQR 27-37) and with 70% of the walking bouts lasting less than 30 seconds. Patients walking ≥600 steps were younger (80.4 years, SD 8.9 vs 82.8 years,SD 7.9, p = 0.050) and had a longer length of stay (7.8 days, SD 5.1 vs 6.1 days, SD 4.1, p = 0.011) than those walking <600 steps. Patients at high risk of bed sores walked less (564 steps, IQR 394-814 vs 626, IQR 526-840) than those with a lower risk of sores.

CONCLUSION

During a hospitalisation for an acute medical illness, patients aged ≥65 years walk a mere 603 steps daily and most of the time for periods of less than 30 seconds. This information should be used to build up future interventional trials or to set mobility goals for patients hospitalised in Swiss hospitals.

Piloting a Mobility Tech Role at an Academic Medical Center

INTRODUCTION

There is often a breakdown in communication between physical therapy and nursing regarding the responsibility of patient mobility. This communication problem contributes to mobility being the most frequently missed clinical intervention. To address this gap, a Mobility Tech (MT) role was implemented at a large academic medical center. The purpose of this article is to describe the implementation of this role.

METHODS

Using the Institute for health care improvement (IHI) model for improvement, iterative small tests of change were developed to integrate the MT role on four acute care units. Using process flow mapping, the team developed a MT workflow that was adapted to create MT protocols.

RESULTS

Program outcomes included fall rates and the highest level of mobility documented by staff. During the MT pilot from February 2020 through June 2020, MTs provided an average of over 500 interventions each month. There was a clinically and statistically significant increase in mobility noted in two of the four pilot units.

CONCLUSION

We have demonstrated that MTs can be safely incorporated into acute care nursing workflow, and comments from staff and patients validate the role is "value added."

Facilitators and barriers to enhancing physical activity in older patients during acute hospital stay: a systematic review

BACKGROUND

To improve older patients' physical activity (PA) behavior, it is important to identify facilitators and barriers to enhancing PA in older patients (≥ 65 years) during hospitalization from the perspectives of patients, caregivers, and healthcare professionals (HCPs).

METHODS

In this systematic review, a search of PubMed, CINAHL, PsycINFO, EMBASE, and Web of Science (January 2000-May 2021) was performed, and quantitative, qualitative, and mixed-methods studies were included. The methodological quality of included studies was assessed using the Mixed Methods Appraisal Tool. Identified facilitators and barriers were categorized using the social ecological model at the intrapersonal, interpersonal, and institutional levels.

RESULTS

The 48 included articles identified 230 facilitators and 342 barriers. The main facilitators at the intrapersonal level included: knowledge, awareness, and attitudes; interpersonal level: social support, including encouragement and interdisciplinary collaboration; and institutional level: stimulating physical environment, patient activities and schedules, and PA protocols. The main barriers at the intrapersonal level included: physical health status, having lines or drains, patients' fear, and HCPs' safety concerns; interpersonal level: patient-HCP relation and HCPs' unclear roles; and institutional level: lack of space and resources, including time and equipment. Best evidence synthesis provided moderate level of evidence for three barriers: patients' unwillingness or refusal to move, patients having symptoms, and patients having lines or drains. No moderate level of evidence was found for facilitators.

CONCLUSION

The PA behavior of older adults during hospitalization is multidimensional. Our overview highlights facilitators and barriers on multilevel scale (intrapersonal, interpersonal, and institutional levels) that guides patients, caregivers, HCPs, and researchers in future clinical practice, and intervention development and implementation.

Barriers and facilitators to mobility of patients hospitalised on an acute medical ward: a systematic review

BACKGROUND

low patient mobility is common during hospitalisation and is associated with adverse outcomes. To change practice, interventions should address barriers and facilitators to mobility. Our aim was to systematically review the literature to provide a synthesised overview of patient-, health care professional (HCP)- and environment-/system-related barriers and facilitators to mobility of patients hospitalised on an acute care medical ward.

METHODS

we searched Medline, Embase, PsycInfo, Web of Science Core Collection, Cochrane CENTRAL, CINHAHL and Google Scholar (inception to 18 October 2021) to identify studies reporting barriers and/or facilitators to mobility of adults hospitalised on an acute medical ward. We applied a deductive and inductive thematic analysis to classify barriers and facilitators into themes and subthemes relevant for clinical practice.

RESULTS

among 26 studies (16 qualitative, 7 quantitative and 3 mixed methods), barriers and facilitators were categorised into 10 themes: patient situation, knowledge, beliefs, experiences, intentions, emotions, social influences, role/identity, implementation/organisation and environment/resources. Barriers included patient characteristics (e.g. impaired cognitive/physical status) and symptoms, HCPs prioritising other tasks over mobility, HCPs labelling patients as 'too sick', fear of injury, lack of time, lack of clarity about responsibility, patient medical devices and non-encouraging environment. Facilitators included knowledge of mobility importance, HCP skills, interdisciplinarity, documentation and unit expectations, encouraging staff, goal individualisation, activity programme, family/visitor/volunteer support and availability of equipment.

CONCLUSION

this synthesised overview of patient-, HCP- and environment-/system-related barriers and facilitators to mobility of adults hospitalised on an acute medical ward can help researchers and clinicians focus on what can realistically be influenced to improve mobility.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021285954.

Development and internal validation of a prediction model to identify older adults at risk of low physical activity levels during hospitalisation: a prospective cohort study

Background

Inactive behaviour is common in older adults during hospitalisation and associated with poor health outcomes. If patients at high risk of spending little time standing/walking could be identified early after admission, they could be given interventions aimed at increasing their time spent standing/walking. This study aims to identify older adults at high risk of low physical activity (PA) levels during hospitalisation.

Methods

Prospective cohort study of 165 older adults (≥ 70 years) admitted to the department of Internal Medicine of Maastricht University Medical Centre for acute medical illness. Two prediction models were developed to predict the probability of low PA levels during hospitalisation. Time spent standing/walking per day was measured with an accelerometer until discharge (≤ 12 days). The average time standing/walking per day between inclusion and discharge was dichotomized into low/high PA levels by dividing the cohort at the median (50.0%) in model 1, and lowest tertile (33.3%) in model 2. Potential predictors—Short Physical Performance Battery (SPPB), Activity Measure for Post-Acute Care (AM-PAC), age, sex, walking aid use, and disabilities in activities of daily living—were selected based on literature and analysed using logistic regression analysis. Models were internally validated using bootstrapping. Model performance was quantified using measures of discrimination (area under the receiver operating characteristic curve (AUC)) and calibration (Hosmer and Lemeshow (H–L) goodness-of-fit test and calibration plots).

Results

Model 1 predicts a probability of spending ≤ 64.4 min standing/walking and holds the predictors SPPB, AM-PAC and sex. Model 2 predicts a probability of spending ≤ 47.2 min standing/walking and holds the predictors SPPB, AM-PAC, age and walking aid use. AUCs of models 1 and 2 were .80 (95% confidence interval (CI) = .73—.87) and .86 (95%CI = .79—.92), respectively, indicating good discriminative ability. Both models demonstrate near perfect calibration of the predicted probabilities and good overall performance, with model 2 performing slightly better.

Conclusions

The developed and internally validated prediction models may enable clinicians to identify older adults at high risk of low PA levels during hospitalisation. External validation and determining the clinical impact are needed before applying the models in clinical practise.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03146-9.

The effectiveness of physical activity interventions using activity trackers during or after inpatient care: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Promoting physical activity (PA) in patients during and/or after an inpatient stay appears important but challenging. Interventions using activity trackers seem promising to increase PA and enhance recovery of physical functioning.

OBJECTIVE

To review the effectiveness of physical activity interventions using activity trackers on improving PA and physical functioning, compared to usual care in patients during and/or after inpatient care. In addition, it was determined whether the following intervention characteristics increase the effectiveness of these interventions: the number of behaviour change techniques (BCTs) used, the use of a theoretical model or the addition of coaching by a health professional.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, EMBASE, Cinahl, SportDiscus and Web of Science databases were searched in March 2020 and updated in March 2021.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomized controlled trials (RCTs) including interventions using activity trackers and feedback on PA in adult patients during, or less than 3 months after, hospitalization or inpatient rehabilitation.

METHODS

Following database search and title and abstract screening, articles were screened on full text for eligibility and then assessed for risk of bias by using the Physiotherapy Evidence Database (PEDro) scale. Meta-analyses, including subgroup analysis on intervention characteristics, were conducted for the outcomes PA and physical functioning.

RESULTS

Overall, 21 RCTs totalling 2355 patients were included. The trials covered a variety of clinical areas. There was considerable heterogeneity between studies. For the 13 studies that measured PA as an outcome variable(N = 1435), a significant small positive effect in favour of the intervention was found (standardized mean difference (SMD) = 0.34; 95%CI 0.12-0.56). For the 13 studies that measured physical functioning as an outcome variable (N = 1415) no significant effect was found (SMD = 0.09; 95%CI -0.02 - 0.19). Effectiveness on PA seems to improve by providing the intervention both during and after the inpatient period and by using a theoretical model, multiple BCTs and coaching by a health professional.

CONCLUSION

Interventions using activity trackers during and/or after inpatient care can be effective in increasing the level of PA. However, these improvements did not necessarily translate into improvements in physical functioning. Several intervention characteristics were found to increase the effectiveness of PA interventions.

TRIAL REGISTRATION

Registered in PROSPERO ( CRD42020175977 ) on March 23th, 2020.

Transforming an Orthopaedic Unit Into an "Age-Friendly" Unit Through Implementation of the American Geriatrics Society's CoCare: Ortho Program

OBJECTIVE

To transform an inpatient orthopaedic unit into an age-friendly unit for geriatric fracture center (GFC) patients.

DESIGN

Pragmatic dissemination study of a continuous quality improvement intervention with episodic data review.

SETTING

Large quaternary care university hospital with no on-site geriatrics program and no dedicated geriatric inpatient unit.

PARTICIPANTS

Individuals 60 years of age and older with fragility fracture of the native proximal femur hospitalized from July 2017 to June 2020.

INTERVENTION

A hospital medicine-orthopaedics comanagement model for a GFC was developed using processes, tools, and education provided by the American Geriatrics Society's AGS CoCare: Ortho program to support the age-friendly 4Ms principles: mentation, mobility, medications, and what matters. Delirium reduction strategies included minimizing sleep interruption through changes in blood draw times, order sets for pain management, and nursing education. Mobility specialists were incorporated to improve early mobilization on the orthopaedic unit.

MAIN OUTCOME MEASUREMENTS

Frequency of weight-bearing on postoperative day 1 and frequency of delirium among GFC patients on the orthopaedic unit were compared with those among concurrent GFC patients on other units.

RESULTS

Frequency of delirium was 26% among patients on the orthopaedic unit versus 35% among those on other units (P = 0.055). Frequency of weight-bearing on post-operative day 1 was 84% among patients on the orthopaedic unit versus 72% among those on other units (P = 0.003).

CONCLUSIONS

AGS CoCare: Ortho is an effective dissemination program for establishing a hospital medicine-orthopaedics comanagement program and making an orthopaedic unit age-friendly in a hospital without onsite geriatricians or a dedicated geriatrics unit.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Barriers and enablers to physical activity behaviour in older adults during hospital stay: a qualitative study guided by the theoretical domains framework

Background

Older adults admitted with an acute medical illness spent little time active during hospitalisation and this has been associated with negative health outcomes. Understanding which barriers and enablers influence the physical activity behaviour of hospitalised older adults is a first step towards identifying potentially modifiable factors and developing, evaluating and implementing targeted interventions aimed at increasing their physical activity behaviour. Using a theoretical framework has been found to be more successful in changing behaviour than using a non-theory driven approach. This study aimed to explore barriers and enablers to physical activity behaviour in older adults admitted to a hospital with an acute medical illness, as perceived by patients and healthcare professionals, and to categorise them using the Theoretical Domains Framework (TDF).

Methods

A qualitative study was conducted at a combined university and regional hospital in the Netherlands between January 2019 and February 2020. Older adults (≥70 years) admitted with an acute medical illness, and healthcare professionals (nurses, physicians, physiotherapists) were recruited using purposive sampling. Semi-structured interviews were audiotaped, transcribed and analysed using directed qualitative content analysis. Barriers and enablers to physical activity behaviour during hospitalisation were identified and coded using the TDF.

Results

Meaning saturation was determined after interviews with 12 patients and 16 healthcare professionals. A large number of barriers and enablers were identified and each categorised to 11 of the 14 domains of the TDF. The ‘Environmental Context and Resources’ domain in particular yielded many examples, and revealed that the hospital environment exerts an inactivating influence on patients.

Conclusions

The large number of identified barriers and enablers highlights the complexity of influencing older adults’ physical activity behaviour during hospitalisation. This overview of barriers and enablers to physical activity behaviour in older adults admitted to a hospital with an acute medical illness represents an initial step towards developing, evaluating and implementing theory-informed behaviour change interventions to improve hospitalised older adults’ physical activity levels. It can assist clinicians and researchers in selecting modifiable factors that can be targeted in future interventions.

Feasibility and implementation fidelity of a co-designed intervention to promote in-hospital mobility among older medical patients-the WALK-Copenhagen project (WALK-Cph)

BACKGROUND

Mobility interventions can prevent functional decline among older patients, but implementation of such interventions may be complicated by barriers in the clinical setting. The WALK-Copenhagen project (WALK-Cph) is aimed at promoting a 24-h mobility among older medical patients during hospitalization. The WALK-Cph intervention was co-designed by researchers and stakeholders to tailor the intervention to the clinical context. The aim of this study was to investigate the feasibility and implementation fidelity of the WALK-Cph intervention before evaluating clinical effectiveness in a randomized controlled trial (ClinicalTrials.gov NCT03825497).

METHODS

The WALK-Cph intervention consisted of six components: a welcome folder explaining the importance of in-hospital activity, a WALK-plan prescribing up to three daily walking sessions during and after hospitalization, a WALK-path in the hallway that patients were motivated to use daily, exercise posters in the hallways and bedrooms, self-service on beverages and clothes, and discharge with a WALK-plan. The present study reports on phase 2 of WALK-Cph and consists of a feasibility and a fidelity component. The study was conducted at the two WALK-Cph intervention departments after the initiation of the WALK-Cph intervention. A cohort of older medical patients (+65) was recruited for the feasibility study to assess recruitment and data collection procedures and the method for assessment of activity. Simultaneously, implementation fidelity was assessed by observing clinical practice and intervention delivery at the intervention departments.

RESULTS

A feasibility cohort of 48 patients was included. Inclusion was considered feasible with recruitment rates between 62% and 70% of all eligible patients. Also, data collection was conducted without obstacles, and all patients accepted to wear activity monitors. The fidelity observations showed that three of the six intervention components were partially implemented as planned whereas three components were not implemented as planned.

CONCLUSION

The WALK-Cph intervention was found feasible, and although the intervention was not implemented with fidelity, the level of fidelity was considered sufficient to continue with further testing of the WALK-Cph intervention in a large-scale trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03825497 (retrospectively registered). Protocol PubMed ID (PMID): 29523569.

Perceived Factors of Influence on the Implementation of a Multidimensional Project to Improve Patients' Movement Behavior During Hospitalization: A Qualitative Study

OBJECTIVE

The aim of this study was to explore perceived factors of influence on the implementation of Hospital in Motion, a multidimensional and multidisciplinary implementation project to improve inpatients' movement behavior.

METHODS

This qualitative study was conducted on 4 wards. Per ward, a tailored action plan was implemented consisting of multiple tools and interventions to stimulate the integration of inpatient physical activity in usual care processes. After implementation, semi-structured interviews were performed with health care professionals and patients to explore perceived factors of influence on the implementation of the Hospital in Motion project. A content analysis was performed using the framework of the Medical Research Council for complex interventions as guidance for the identification of categories and themes.

RESULTS

In total, 16 interviews were conducted with health care professionals and 12 with patients. The results were categorized into the 3 key components of the Medical Research Council framework: implementation, mechanisms of impact, and context. An important factor of influence within the theme "implementation" was the iterative and multidisciplinary approach. Within the theme "mechanisms of impact," continuous attention and the interaction of multiple interventions, tailored to the target group and targeting multiple dimensions (individual, inter-professional, community and society), were perceived as important. Within the theme "context," the intrinsic motivation and inter-professional, community and societal culture towards physical activity was perceived to be of influence.

CONCLUSION

Impact can be achieved and maintained by creating continuous attention to inpatient physical activity and by the interaction between different interventions and dimensions during implementation. To maintain enough focus, the amount of activities at one time should be limited.

IMPACT

To improve inpatients' movement behavior, implementation project teams should be multidisciplinary and should implement a small set of tailored interventions that target multiple dimensions. Intermediate evaluation of the implementation process, strategies, and interventions is recommended.

Early mobilization in enhanced recovery after surgery pathways: current evidence and recent advancements

Early mobilization is a crucial component of enhanced recovery after surgery (ERAS) pathways that counteract the adverse physiological consequences of surgical stress and immobilization. Early mobilization reduces the risk of postoperative complications, accelerates the recovery of functional walking capacity, positively impacts several patient-reported outcomes and reduces hospital length of stay, thereby reducing care costs. Modifiable barriers to early mobilization include a lack of education and a lack of resources. Education and clinical decision-making tools can improve compliance with ERAS mobilization recommendations and create a culture that prioritizes perioperative physical activity. Recent advances include real-time feedback of mobilization quantity using wearable technology and combining ERAS with exercise prehabilitation. ERAS guidelines should emphasize the benefits of structured postoperative mobilization.

A mixed-methods feasibility study of a sit-to-stand based exercise programme to maintain knee-extension muscle strength for older patients during hospitalisation

Objectives:

To determine the acceptability of an exercise programme and to identify barriers and facilitators to compliance with the programme from the participants’ perspective.

Methods:

Patients aged 75 years or older were recruited within the first 36 hours of hospital admission. Participants were randomised to complete two strengthening-based (intervention arm) or stretching-based (control arm) exercise sessions per-day. At hospital discharge, participants were asked to take part in interviews with a member of the research team exploring the barriers and facilitators to adherence to the intervention.

Results:

15 participants (7 intervention arm, 8 control arm) were recruited before the trial was stopped due to COVID-19. Both groups showed reductions in knee-extension strength, and improvements in functional mobility at discharge from hospital. A total of 23/60 intervention sessions were classed as ‘complete’, 12/60 as partially complete, and 25/60 were missed entirely. Eight participants took part in interviews. Intrinsic factors that impacted participation in the research, related to current health, health beliefs, and experience of multi-morbidity or functional decline. Staff had both a positive and negative effect on participant adherence to the intervention.

Conclusions:

The exercise intervention was well received, with most participants describing health benefits, though intervention fidelity was lower than expected.

Physical activity levels in hospitalised adults with burn injuries

Physical activity behaviour has not been previously described in hospitalised adults with burn injuries. This prospective, cross-sectional study used a standardised behavioural mapping protocol to observe patient behaviour related to physical activity over a 12-hour period on one weekday in a quaternary referral specialist burn centre. Structured observations were recorded for each of four domains: 1) patient location, 2) position, 3) activity performed and 4) the presence of others. Observations were summarised across all participants as median (IQR) proportion of time. Participants (n=17) were predominantly male (82%) with a mean age of 44.3 (SD 15.2) years, a mean burn size of 34.9% (SD 26.7) total body surface area and a median hospital length of stay of 18 (IQR 6-49) days at time of observation. Participants spent a median of 83% (IQR 73-93) of time in their bedroom, 92% (IQR 68-97) of time in or on their bed and a median of 5% (IQR 3-13) of time mobilising. Exercise accounted for 10% (IQR 8-17) of activity related observations. A median of 68% (IQR 39-83) of time was spent alone. Results suggest time spent engaging in physical activity is low. Further studies are required to investigate motivators and barriers to performing physical activity in this population. This will consequently inform the development and implementation of appropriate strategies to improve physical activity behaviour in this cohort.

Barriers and enablers to physical activity in patients during hospital stay: a scoping review

BACKGROUND

Low levels of physical activity are common during the hospital stay and have been associated with negative health outcomes. Understanding barriers and enablers to physical activity during a hospital stay can improve the development and implementation of tailored interventions aimed at improving physical activity. Previous studies have identified many barriers and enablers, but a comprehensive overview is lacking. This study aimed to identify and categorize all published patient- and healthcare professional-reported barriers and enablers to physical activity during a hospital stay for acute care, using the Theoretical Domains Framework (TDF).

METHODS

We conducted a scoping review of Dutch and English articles using MEDLINE, CINAHL Plus, EMBASE, PsycINFO, and Cochrane Library (inception to September 2020), which included quantitative, qualitative, and mixed-methods studies reporting barriers and enablers to physical activity during a hospital stay for acute care, as perceived by patients or healthcare professionals. Two reviewers systematically extracted, coded, and categorized all barriers and enablers into TDF domains.

RESULTS

Fifty-six articles were included in this review (32 qualitative, 7 quantitative, and 17 mixed-methods). In total, 264 barriers and 228 enablers were reported by patients, and 415 barriers and 409 enablers by healthcare professionals. Patient-reported barriers were most frequently assigned to the TDF domains Environmental Context & Resources (ECR, n = 148), Social Influences (n = 32), and Beliefs about Consequences (n = 25), while most enablers were assigned to ECR (n = 67), Social Influences (n = 54), and Goals (n = 32). Barriers reported by healthcare professionals were most frequently assigned to ECR (n = 210), Memory, Attention and Decision Process (n = 45), and Social/Professional Role & Identity (n = 31), while most healthcare professional-reported enablers were assigned to the TDF domains ECR (n = 143), Social Influences (n = 76), and Behavioural Regulation (n = 54).

CONCLUSIONS

Our scoping review presents a comprehensive overview of all barriers and enablers to physical activity during a hospital stay and highlights the prominent role of the TDF domains ECR and Social Influences in hospitalized patients' physical activity behavior. This TDF-based overview provides a theoretical foundation to guide clinicians and researchers in future intervention development and implementation.

SCOPING REVIEW REGISTRATION

No protocol was registered for this review.

Applicability of the GLIM criteria for the diagnosis of malnutrition in older adults in the emergency ward: A pilot validation study

BACKGROUND & AIMS

Acutely ill older adults are at higher risk of malnutrition. This study aimed to explore the applicability and accuracy of the GLIM criteria to diagnose malnutrition in acutely ill older adults in the emergency ward (EW).

METHODS

We performed a retrospective secondary analysis, of an ongoing cohort study, in 165 participants over 65 years of age admitted to the EW of a Brazilian university hospital. Nutrition assessment included anthropometry, the Simplified Nutritional Assessment Questionnaire (SNAQ), the Malnutrition Screening Tool (MST), and the Mini-Nutritional Assessment (MNA). We diagnosed malnutrition using GLIM criteria, defined by the parallel presence of at least one phenotypic [nonvolitional weight loss (WL), low BMI, low muscle mass (MM)] and one etiologic criterion [reduced food intake or assimilation (RFI), disease burden/inflammation]. We used the receiver operating characteristic (ROC) curves and Cox and logistic regression for data analyses.

RESULTS

GLIM criteria, following the MNA-SF screening, classified 50.3% of participants as malnourished, 29.1% of them in a severe stage. Validation of the diagnosis using MNA-FF as a reference showed good accuracy (AUC = 0.84), and moderate sensitivity (76%) and specificity (75.1%). All phenotypic criteria combined with RFI showed the best metrics. Malnutrition showed a trend for an increased risk of transference to intensive care unit (OR = 2.08, 95% CI 0.99, 4.35), and severe malnutrition for in-hospital mortality (HR = 4.23, 95% CI 1.2, 14.9).

CONCLUSION

GLIM criteria, following MNA-SF screening, appear to be a feasible approach to diagnose malnutrition in acutely ill older adults in the EW. Nonvolitional WL combined with RFI or acute inflammation were the best components identified and are easily accessible, allowing their potential use in clinical practice.