Ban Bedcentricity: A Multifaceted Innovation to Reduce Sedentary Behavior of Patients During the Hospital Stay

Development of a goal-directed movement intervention (GOAL) using a movement sensor for hospitalized patients: An intervention mapping approach

OBJECTIVE

To describe the development of a goal-directed movement intervention in two medical wards, including recommendations for implementation and evaluation.

DESIGN

Implementation Research.

SETTING

Pulmonology and nephrology/gastroenterology wards of the University Medical Centre Utrecht, The Netherlands.

PARTICIPANTS

Seven focus groups were executed including 28 nurses, 7 physical therapists and 15 medical specialists. Patients' perceptions were repeatedly assessed during the iterative steps of the intervention development.

INTERVENTION

Interventions were targeted to each ward's specific character, following an Intervention Mapping approach using literature and research meetings. Main measures: Intervention components were linked to Behavior Change Techniques and implementation strategies will be selected using the Expert Recommendation Implementing Change tool. Evaluation outcomes like number of patients using the movement intervention will be measured, based on the taxonomy of Proctor.

RESULTS

The developed intervention consists of: insight in patients movement behavior (monitoring & feedback), goal setting (goals & planning) and adjustments to the environment (associations & antecedents). The following implementation strategies are recommended: to conduct educational meetings, prepare & identify champions and audit & provide feedback. To measure service and client outcomes, the mean level of physical activity per ward can be evaluated and the Net Promoter Score can be used.

CONCLUSION(S)

This study shows the development of a goal-directed movement intervention aligned with the needs of healthcare professionals. This resulted in an intervention consisting of feedback & monitoring of movement behavior, goal setting and adjustments in the environment. Using a step-by-step iterative implementation model to guide development and implementation is recommended.

Time-motion observations to characterize the developmental environment in a paediatric post-acute care hospital

BACKGROUND

Chronically hospitalized children are at risk for neurodevelopmental delay, compounded by restricted social interactions, movement and environmental stimulation. We measured patients' movements and interactions to characterize developmentally relevant aspects of our inpatient environment and identify opportunities for developmental enrichment.

METHODS

As part of a quality improvement initiative to inform neurodevelopmental programming for children with medical complexity at our paediatric post-acute care specialty hospital, we conducted >232 hours of time-motion observations. Trained observers followed 0- to 5-year-old inpatients from 7 am to 7 pm on weekdays, categorizing observations within five domains: Where, With, Position, State and Environment. Observations were collected continuously utilizing REDCap on iPads. A change in any domain initiated a new observation.

RESULTS

Patients were median 1 year and 8 months of age (range 2 months to 3 years 9 months) with a median length of hospitalization of 514 days (range 66-1298). In total, 2636 unique observations (or median 134 observations per patient-day [range 95-210]) were collected. Patients left their rooms up to 4 times per day for median 1 h and 34 min (range 41 min to 4 h:30 min). Patients spent 4 h:6 min (2 h:57 min to 6 h:30 min) interacting with someone and 3 h:51 min (57 min to 6 h:36 min) out of bed each day. Patients were simultaneously out of their beds, interacting with someone and awake for 2 h:21 min (51 min to 4 h:19 min) each day.

CONCLUSIONS

Despite a care model prioritizing time out of bed and social interaction, time-motion observations indicate patients spent many of their waking hours in bed and alone. Quantifying our inpatients developmental opportunities will inform neurodevelopmental programming initiatives.

Improving physical activity in hospitalized patients: The preliminary effectiveness of a goal-directed movement intervention

OBJECTIVE

To evaluate the preliminary effectiveness of a goal-directed movement intervention using a movement sensor on physical activity of hospitalized patients.

DESIGN

Prospective, pre-post study.

SETTING

A university medical center.

PARTICIPANTS

Patients admitted to the pulmonology and nephrology/gastro-enterology wards.

INTERVENTION

The movement intervention consisted of (1) self-monitoring of patients' physical activity, (2) setting daily movement goals and (3) posters with exercises and walking routes. Physical activity was measured with a movement sensor (PAM AM400) which measures active minutes per day.

MAIN MEASURES

Primary outcome was the mean difference in active minutes per day pre- and post-implementation. Secondary outcomes were length of stay, discharge destination, immobility-related complications, physical functioning, perceived difficulty to move, 30-day readmission, 30-day mortality and the adoption of the intervention.

RESULTS

A total of 61 patients was included pre-implementation, and a total of 56 patients was included post-implementation. Pre-implementation, patients were active 38 ± 21 minutes (mean ± SD) per day, and post-implementation 50 ± 31 minutes per day (Δ12, P = 0.031). Perceived difficulty to move decreased from 3.4 to 1.7 (0-10) (Δ1.7, P = 0.008). No significant differences were found in other secondary outcomes.

CONCLUSIONS

The goal-directed movement intervention seems to increase physical activity levels during hospitalization. Therefore, this intervention might be useful for other hospitals to stimulate inpatient physical activity.

'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.

Rapid Improvements in Physical Activity and Sedentary Behavior in Patients With Acute Myocardial Infarction Immediately Following Hospital Discharge

Background Little is known about changes in physical activity (PA) and sedentary behavior (SB) patterns in the acute phase of a myocardial infarction (MI). We objectively assessed PA and SB during hospitalization and the first week after discharge. Methods and Results Consecutively admitted patients hospitalized with an MI were approached to participate in this prospective cohort study. SB, light-intensity PA, and moderate-vigorous intensity PA were objectively assessed for 24 h/d during hospitalization and up to 7 days after discharge in 165 patients. Changes in PA and SB from the hospital to home phase were evaluated using mixed-model analyses, and outcomes were stratified for predefined subgroups based on patient characteristics. Patients (78% men) were aged 65±10 years and diagnosed with ST-segment-elevation MI (50%) or non-ST-segment-elevation MI (50%). Sedentary time was high during hospitalization (12.6 [95% CI, 11.8-13.7] h/d) but substantially decreased following transition to the home environment (-1.8 [95% CI, -2.4 to -1.3] h/d). Furthermore, the number of prolonged sedentary bouts (≥60 minutes) decreased between hospital and home (-1.6 [95% CI, -2.0 to -1.2] bouts/day). Light-intensity PA (1.1 [95% CI, 0.8-1.6] h/d) and moderate-vigorous intensity PA (0.2 [95% CI, 0.1-0.3] h/d) were low during hospitalization but significantly increased following transition to the home environment (light-intensity PA: 1.8 [95% CI, 1.4-2.3] h/d; moderate-vigorous intensity PA: 0.4 [95% CI, 0.3-0.5] h/d; both P<0.001). Improvements in PA and SB were similar across groups, except for patients who underwent coronary artery bypass grafting and who did not improve their PA patterns after discharge. Conclusions Patients with MI demonstrate high levels of SB and low PA volumes during hospitalization, which immediately improved following discharge at the patient's home environment. Registration URL: trialsearch.who.int/; Unique identifier: NTR7646.

The Johns Hopkins Activity and Mobility Promotion Program: A Framework to Increase Activity and Mobility Among Hospitalized Patients

BACKGROUND

Greater mobility and activity among hospitalized patients has been linked to key outcomes, including decreased length of stay, increased odds of home discharge, and fewer hospital-acquired morbidities. Systematic approaches to increasing patient mobility and activity are needed to improve patient outcomes during and following hospitalization.

PROBLEM

While studies have found the Johns Hopkins Activity and Mobility Promotion (JH-AMP) program improves patient mobility and associated outcomes, program details and implementation methods are not published.

APPROACH

JH-AMP is a systematic approach that includes 8 steps, described in this article: (1) organizational prioritization; (2) systematic measurement and daily mobility goal; (3) barrier mitigation; (4) local interdisciplinary roles; (5) sustainable education and training; (6) workflow integration; (7) data feedback; and (8) promotion and awareness.

CONCLUSIONS

Hospitals and health care systems can use this information to guide implementation of JH-AMP at their institutions.

A unit-based, multi-center evaluation of adopting mobility measures and daily mobility goals in the hospital setting

BACKGROUND

Promoting patient mobility helps improve patient outcomes, but mobility status is not widely tracked nor do patients have specific individualized mobility goals.

PURPOSE

We evaluated nursing adoption of mobility measures and daily mobility goal achievement using the Johns Hopkins Mobility Goal Calculator (JH-MGC), a tool to guide an individualized patient mobility goal based on the level of mobility capacity.

METHOD

Built on a translating research into practice framework, the Johns Hopkins Activity and Mobility Promotion (JH-AMP) program was the vehicle to promote use of the mobility measures and the JH-MGC. We evaluated a large-scale implementation effort of this program on 23 units across two medical centers.

FINDINGS

Units significantly improved documentation compliance to mobility measures and achieving daily mobility goals. Units with the highest documentation compliance rates had higher rates of daily mobility goal achievement, especially for longer distance ambulation goals.

DISCUSSION

The JH-AMP program improved adoption of mobility status tracking and higher nursing inpatient mobility levels.

Healthcare professionals feel empowered by implementing a hospital-based multifaceted intervention: a qualitative study using inductive thematic analysis

Background

Most patients are insufficiently physically active during their hospital stay, and this is associated with poor health and delayed recovery. Hospital-based multifaceted interventions aim to encourage patients to engage in physical activity. Ban Bedcentricity is one such intervention. Its value – and that of others similar to it – for healthcare professionals has not been studied yet. Whether an intervention looks and feels right, and whether it does the job well, is important for healthcare professionals and thus its use. Understanding value for healthcare professionals seems crucial for the long-term adoption and implementation of interventions. Therefore, we studied healthcare professionals’ perceptions of value in terms of the implementation of a multifaceted intervention that aimed at improving physically active behaviour in patients during their hospital stay.

Methods

Using Ban Bedcentricity as a case study to focus on healthcare professionals’ perceptions about multifaceted interventions, we conducted a qualitative study between November 2019 and September 2020. Semi-structured interviews were conducted with purposefully selected physicians, physiotherapists, and nurses (assistants) until theoretical data saturation was reached. Inductive thematic analysis was used to identify key themes and develop a conceptual model.

Results

We interviewed 15 healthcare professionals and formulated six key themes from these interviews. The participants said that Ban Bedcentricity empowered them in their beliefs about the importance of physical activity for hospitalized patients (theme 1). They also indicated that it made them more aware of the value of physical activity (theme 2) and skilled to promote physical activity as part of their professional role (theme 3). Similarly, they noted that it enabled them to shift from providing hands-on support to verbal coaching (theme 4). Other aspects that the participants valued were the increased possibilities for teamwork (theme 5) and the routinized physical activity promotion in usual care (theme 6). The challenges discussed by the participants were prioritizing activities that promoted physical activity, especially because of a high workload, and avoiding relapses of new routinized work practices related to physical activity promotion if insufficient long-term support and training were provided.

Conclusions

Our conceptual model shows that the implementation of a hospital-based multifaceted intervention by healthcare professionals empowers their beliefs, and improves their awareness, skills, professional roles, teamwork, and work routinization. These values are typically overlooked, despite potentially being important facilitators for long-term implementation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08310-w.

The Better By Moving study: A multifaceted intervention to improve physical activity in adults during hospital stay

Objective

‘Better By Moving’ is a multifaceted intervention developed and implemented in collaboration with patients and healthcare professionals to improve physical activity in hospitalized adults. This study aimed to understand if, how and why ‘Better By Moving’ resulted in higher levels of physical activity by evaluating both outcomes and implementation process.

Design

Mixed-methods study informed by the Medical Research Council guidance.

Setting

Tertiary hospital.

Participants

Adult patients admitted to surgery, haematology, infectious diseases and cardiology wards, and healthcare professionals.

Measures

Physical activity was evaluated before and after implementation using the Physical Activity Monitor AM400 on one random day during hospital stay between 8 am and 8 pm. Furthermore, the time spent lying on bed, length of stay and discharge destination was investigated. The implementation process was evaluated using an audit trail, surveys and interviews.

Results

There was no significant difference observed in physical activity (median [IQR] 23 [12–51] vs 27 [17–55] minutes, P = 0.107) and secondary outcomes before-after implementation. The intervention components’ reach was moderate and adoption was low among patients and healthcare professionals. Patients indicated they perceived more encouragement from the environment and performed exercises more frequently, and healthcare professionals signalled increased awareness and confidence among colleagues. Support (priority, resources and involvement) was perceived a key contextual factor influencing the implementation and outcomes.

Conclusion

Although implementing ‘Better By Moving’ did not result in significant improvements in outcomes at our centre, the process evaluation yielded important insights that may improve the effectiveness of implementing multifaceted interventions aiming to improve physical activity during hospital stay.

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.

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.