Research has shown that when patients are hospitalized, they spend most of their time lying in their hospital bed even when they can move — and that lack of mobility can lead to worsened health outcomes. University of Colorado Department of Medicine faculty member and physician Katie Raffel, MD, sees this happen firsthand. She describes a particularly memorable case of a patient who was hospitalized due to a complication of their cancer. By the time the patient was discharged, they had lost some of their ability to move.
“They were not eligible to resume their cancer treatment because of their functional status decline, given that the treatment is intense and hard on the body. In some ways, the care team felt responsible for what happened. I remember how disappointed the patient and family was,” says Raffel, an associate professor in the Division of Hospital Medicine.
Now, as the medical director of the inpatient medicine units at the University of Colorado Hospital and a faculty member in the Institute for Healthcare Quality, Safety and Efficiency, Raffel is helping to lead collaborative efforts so hospitalized patients can safely move more.
“Increasing patient mobility has historically been difficult because of how multifactorial and complex the issue is,” she says. “I was drawn to CU because of its innovation and investment in improving quality and safety measures like mobility. It’s fun to be in an environment where people are working to create change.”
A systematic review published in 2020 found that hospitalized adults spend between 87% and 100% of their time sitting or lying in their hospital bed. The statistic is not only shocking, Raffel says, but it also matters in the context of patient health.
“Mobility in the hospital ties so closely to other health outcomes we care about. We know that reduced mobility is associated with pressure injuries, higher rates of delirium, hospital-acquired pneumonias, and there is some suspicion that it is also associated with falls in the hospital,” she says. “Ensuring that patients are active during their hospitalization helps to prevent a loss of function.”
Despite the need for patient mobilization, Raffel says there are several barriers clinicians face. For one, many patients assume they must remain in bed until they have recovered. The hospital environment also makes it difficult for patients to move, given that patients are often attached to monitors, drains, and tubes.
“Mobility issues are common even among people who have strong mobility prior to hospitalization,” Raffel says. “A few years ago, I had a brief hospitalization and wanted to get up from my bed to walk to the restroom, but I struggled to move. I had two monitors attached to me and the bed was difficult to get up from. It was very humbling and a reminder of how much hospitalization can affect your mobility even when you usually are highly independent.”
Other challenges include limited supplies, such as not having enough walkers in the hospital for patients to use, and workforce barriers.
“A majority of our patients need some type of support, whether that is someone helping detach the monitors so a patient can move or helping a patient stand and walk,” Raffel says. “For a long time, among the workforce in the hospital, it was unclear whose responsibility these mobility efforts were.”
Another factor that has made mobilization difficult is the concern about patients falling. The number of patient falls that occur in a hospital is a publicly reported safety measure.
“In that way, sometimes we have over-emphasized prevention of falls to the detriment of people's mobility. We tell people, ‘Don’t get out of bed because then you can fall.’ But that can result in patients losing important function because of a lack of mobility,” she says. “Both of these issues — falls and mobility — are in tension with one another, especially for older adults.”
Despite the complexity of patient mobility, University of Colorado Hospital and CU leaders have spent years innovating new methods to address this issue. As medical director for inpatient medicine units at the University of Colorado Hospital, Raffel partners with six clinical units, which typically have about 175 patients across them.
“In our units, we care for almost everything outside of cancer and surgical care. Our patients, for instance, may be hospitalized for pneumonia, due to a liver disease complication, or for help managing a substance use disorder,” she says.
One of the six units Raffel directs is Acute Care for the Elder, an inpatient ward service that cares for hospitalized patients over the age of 70. For older adults, a lack of mobility can be especially impactful as patients can rapidly lose muscle mass if they are not moving.
“Our goal is for our patients to leave the hospital with the same functional status that they entered with, because it’s so important that patients can go back to living independently if that is how they were previously living,” she says. “Otherwise, they may have to go to a post-acute care or even a long-term care setting.”
Recognizing this need, one of the strategies Raffel’s therapy and nursing colleagues enacted was a process to measure and track the mobility of hospitalized patients — something that was not previously done. The hospital employs two methods of tracking mobility: the Activity Measure for Post-Acute Care (AM-PAC) scoring system, which assesses someone’s current functional ability, and the Johns Hopkins Highest Level of Mobility (JH-HLM) Scale, which measures what activity a patient has accomplished for the day.
“A big first step for us, as a hospital, was standardizing the assessment of mobility and making that visible. Now, we can know what a patient is capable of, what their goals are, and how many times they’ve achieved that goal,” Raffel says. “Our ultimate goal is for at least 75% of our patients to achieve their individual mobility goal three times a day, whether that be simply transferring from their hospital bed to a chair, walking to the bathroom and back, or walking the halls.”
The hospital also invested in increasing its resources, purchasing an influx of walkers so that every room on the Acute Care for the Elder unit has a walker for patients to use.
Raffel says one of the most important changes, however, was increasing the clinical team workforce by hiring a new position to help patients achieve their mobility goals — a role appropriately titled “mobility technician.” These staff members see between 18 and 25 patients a day, partnering with nursing team members to help patients safely move in the hospital. The position started as a pilot initiative, but it was so successful that Raffel estimates the hospital now has over 30 mobility technicians visiting patients.
Raffel has already seen the positive impact of these changes on patients. Before, when a patient would reach their hospital discharge day, many of them realized that their mobility had decreased and they were not able to perform the activities they used to, such as walking or getting dressed on their own.
“As physicians, we think about the medical components of that transition of a patient from the hospital to their home, but what patients and families really care about is being able to go back to their normal living. Traditionally, we wouldn’t counsel them on what their physical limitations may be and what they should expect during the recovery process,” Raffel said. “Now, because the hospital is tracking their mobility every day, patients and families are more aware of their capabilities and can plan beforehand. It has started the dialogue sooner and has created so much more partnership.”
Raffel and the University of Colorado Hospital Mobility Implementation Steer team continue to brainstorm how the hospital can improve its mobilization efforts. For instance, the hospital is still adjusting how it determines which patients the mobility technicians should prioritize visiting in a given shift. Looking ahead, they hope to see future research on what the optimal team structure is to promote mobilization, whether data shows that improved patient mobility reduces the likelihood of falling, and if the mobility efforts at CU are successfully preventing patients from declining in their physical abilities and reducing the likelihood of having to go to a care facility after discharge.
“There are still challenges we face, and we have a long way to go before we reach our mobility goals. But this effort is an interprofessional partnership, and the combination of leaders from the areas of hospital medicine, nursing, physical therapy, and information technology has really made a difference,” she says. “A decade ago, these types of efforts weren’t really talked about, but today, it is a priority for us, and I believe we will see the downstream benefits of these patient-centered mobilization efforts.”
Image at top: A unit in the University of Colorado Hospital celebrates receiving the "golden walker" award, which recognizes excellent work. Image courtesy of Katie Raffel, MD.