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NIHR Signal Getting hospital patients up and moving shortens stay and improves fitness

Published on 16 April 2019

doi: 10.3310/signal-000759

Interventions to encourage patients admitted to hospital for medical problems to get out of bed and walk around increases their mobility, without increasing their risk of falls.

Older inpatients frequently spend much of their time in bed, which risks a loss of physical condition and muscle tone. This can make it harder for them to manage independently at home, and may contribute to delayed discharge.

A review summarised thirteen trials from the UK, Europe and Australia, involving 2,703 adults of average age 75, admitted to hospital for medical reasons. It found significant improvements in walking speed (a measure of fitness) among those who took part in programmes to encourage mobilisation, compared with patients who did not. Length of stay was on average two days shorter.

Encouraging mobilisation among hospital in-patients may be a relatively low cost and effective way of reducing hospital stays and improving patient well-being.

Share your views on the research.

Why was this study needed?

There were 19.7 million hospital admissions in the UK from 2016 to 2017, and people over 65 accounted for 6.3 million of these. Advice for people being admitted to hospital recommends keeping mobile to avoid problems like pressure sores and blood clots. However, that may not be easy for older, frail people who need help to get out of bed.

Prolonged bed rest is thought to reduce the ability to walk independently, for between 16% and 65% of older people. This could hasten their loss of physical function and increase deconditioning. They may lose the ability to live independently, resulting in the need for additional social or healthcare support. This could potentially delay discharge from hospital until support can be put in place.

The aim of the study was to assess the impact of interventions to promote mobilisation on the physical function of older adult medical inpatients.

What did this study do?

This was a systematic review and meta-analysis of 13 randomised controlled trials including 2,703 adults with an average age of 75 admitted to hospital with medical diagnoses. These included blood clots, heart failure, pneumonia and acute or chronic illnesses. The authors excluded people admitted for surgery or with mental health problems.

Any programmed intervention which aimed to encourage mobilisation in hospital, by any healthcare professional, was eligible for inclusion. Interventions included moving from the bed to sitting, standing, walking and exercises. Control groups were treated according to usual care.

Most studies were of moderate quality, but wide variation between each study makes any result more likely to have occurred by chance. There was also evidence of publication bias, where only studies with positive results are published, which could have suppressed some negative findings. The studies were more than ten years old.

What did it find?

  • Mobilisation programmes improved walking ability compared with the control group (mean difference 0.24 metres per second, 95% confidence interval [CI] 0.01 to 0.48; six studies, 496 participants). This equates to walking an extra 86 metres over a six-minute walking test.
  • There was no difference between the groups for balance, measured using the Timed Up and Go test (median effect size 0.8, 95% CI -0.31 to 1.90; five studies, 1,175 participants).
  • Participants randomised to mobilisation programmes stayed in hospital on average 2.18 days less than the control group, although this was not a primary endpoint so there is less certainty in this result (95% CI -3.44 to -0.92; five studies, 1,355 participants).
  • Amongst patients with pulmonary embolism (clot in the lungs), fewer developed new clots in the lungs on the mobilisation programmes: 9 (5.4%) new clots versus 21(13%) treated with usual care (odds ratio [OR] 0.33, 95% CI 0.14 to 0.78; two studies, 321 participants).
  • There was no difference in the rate of falls in hospital, occurring in 44.4% of the mobilisation group compared with 44.6% of the control group (OR 0.62, 95% CI 0.13 to 3.03; two studies, 855 participants).

What does current guidance say on this issue?

There is no current national guidance on the mobilisation of inpatients in hospital for medical treatment, in contrast to guidance for mobilisation after surgery. NICE guidance on hip replacement, for example, states that patients should be encouraged to become mobile on the day after surgery, and should be offered mobilisation opportunities at least daily.

Advice for patients going into hospital suggests that they should aim to remain mobile.

What are the implications?

The results of the study suggest that encouraging mobilisation in medical patients could reduce the average length of stay by two days for an older person admitted to hospital for medical treatment, compared with usual care. That would be a considerable benefit for hospitals struggling with bed shortages and budgets.

The advantage to the patient of retaining or even improving their physical functioning would also add to their quality of life and possibly maintain their independence post-discharge. The possible benefits of introducing mobilisation programmes would seem to outweigh risks, though the high rate of falls in both groups while in hospital seems a cause for concern. We do not know exactly what kind of support at what level of intensity by what professional (therapist, nurse or support staff) is most effective and cost-effective to achieve these benefits. Clinicians and hospital managers should consider their introduction, ideally with monitoring of the results.

Citation and Funding

Cortes OL, Delgado S, Esparza M. Systematic review and meta-analysis of experimental studies: in-hospital mobilization for patients admitted for medical treatment. J Adv Nurs. 2019; January 22. doi: 10.1111/jan.13958.  [E-pub ahead of print].

Funded by a grant from the Colombia Department of Science, Technology and Innovation (COLCIENCIAS).

Bibliography

NICE. Hip fracture: management. CG124. London: National Institute for Health and Care Excellence; 2011.

NHS website. Staying in hospital as an inpatient. London: Department of Health and Social Care; updated 2019.

Why was this study needed?

There were 19.7 million hospital admissions in the UK from 2016 to 2017, and people over 65 accounted for 6.3 million of these. Advice for people being admitted to hospital recommends keeping mobile to avoid problems like pressure sores and blood clots. However, that may not be easy for older, frail people who need help to get out of bed.

Prolonged bed rest is thought to reduce the ability to walk independently, for between 16% and 65% of older people. This could hasten their loss of physical function and increase deconditioning. They may lose the ability to live independently, resulting in the need for additional social or healthcare support. This could potentially delay discharge from hospital until support can be put in place.

The aim of the study was to assess the impact of interventions to promote mobilisation on the physical function of older adult medical inpatients.

What did this study do?

This was a systematic review and meta-analysis of 13 randomised controlled trials including 2,703 adults with an average age of 75 admitted to hospital with medical diagnoses. These included blood clots, heart failure, pneumonia and acute or chronic illnesses. The authors excluded people admitted for surgery or with mental health problems.

Any programmed intervention which aimed to encourage mobilisation in hospital, by any healthcare professional, was eligible for inclusion. Interventions included moving from the bed to sitting, standing, walking and exercises. Control groups were treated according to usual care.

Most studies were of moderate quality, but wide variation between each study makes any result more likely to have occurred by chance. There was also evidence of publication bias, where only studies with positive results are published, which could have suppressed some negative findings. The studies were more than ten years old.

What did it find?

  • Mobilisation programmes improved walking ability compared with the control group (mean difference 0.24 metres per second, 95% confidence interval [CI] 0.01 to 0.48; six studies, 496 participants). This equates to walking an extra 86 metres over a six-minute walking test.
  • There was no difference between the groups for balance, measured using the Timed Up and Go test (median effect size 0.8, 95% CI -0.31 to 1.90; five studies, 1,175 participants).
  • Participants randomised to mobilisation programmes stayed in hospital on average 2.18 days less than the control group, although this was not a primary endpoint so there is less certainty in this result (95% CI -3.44 to -0.92; five studies, 1,355 participants).
  • Amongst patients with pulmonary embolism (clot in the lungs), fewer developed new clots in the lungs on the mobilisation programmes: 9 (5.4%) new clots versus 21(13%) treated with usual care (odds ratio [OR] 0.33, 95% CI 0.14 to 0.78; two studies, 321 participants).
  • There was no difference in the rate of falls in hospital, occurring in 44.4% of the mobilisation group compared with 44.6% of the control group (OR 0.62, 95% CI 0.13 to 3.03; two studies, 855 participants).

What does current guidance say on this issue?

There is no current national guidance on the mobilisation of inpatients in hospital for medical treatment, in contrast to guidance for mobilisation after surgery. NICE guidance on hip replacement, for example, states that patients should be encouraged to become mobile on the day after surgery, and should be offered mobilisation opportunities at least daily.

Advice for patients going into hospital suggests that they should aim to remain mobile.

What are the implications?

The results of the study suggest that encouraging mobilisation in medical patients could reduce the average length of stay by two days for an older person admitted to hospital for medical treatment, compared with usual care. That would be a considerable benefit for hospitals struggling with bed shortages and budgets.

The advantage to the patient of retaining or even improving their physical functioning would also add to their quality of life and possibly maintain their independence post-discharge. The possible benefits of introducing mobilisation programmes would seem to outweigh risks, though the high rate of falls in both groups while in hospital seems a cause for concern. We do not know exactly what kind of support at what level of intensity by what professional (therapist, nurse or support staff) is most effective and cost-effective to achieve these benefits. Clinicians and hospital managers should consider their introduction, ideally with monitoring of the results.

Citation and Funding

Cortes OL, Delgado S, Esparza M. Systematic review and meta-analysis of experimental studies: in-hospital mobilization for patients admitted for medical treatment. J Adv Nurs. 2019; January 22. doi: 10.1111/jan.13958.  [E-pub ahead of print].

Funded by a grant from the Colombia Department of Science, Technology and Innovation (COLCIENCIAS).

Bibliography

NICE. Hip fracture: management. CG124. London: National Institute for Health and Care Excellence; 2011.

NHS website. Staying in hospital as an inpatient. London: Department of Health and Social Care; updated 2019.

Systematic Review and Meta-Analysis of Experimental Studies: In-hospital Mobilization for Patients Admitted for Medical Treatment

Published on 24 January 2019

Cortes, O. L.,Delgado, S.,Esparza, M.

J Adv Nurs , 2019

AIM: To determine the impact of strategies to promote mobilization on physical function in hospitalized adults with medical conditions. BACKGROUND: Slow progress is noted on the promotion of mobilization during hospitalization for adult patients admitted for medical conditions. This may reflect the limited evidence on the evaluation of the impact of progressive mobilization activities on clinical endpoints in adult patients throughout hospitalization. DESIGN: A systematic review and meta-analysis of published randomized controlled trials in any language. DATA RESOURCES: The literature search was performed in the MEDLINE, CINAHL online, HealthStar, EMBASE, the Cochrane Library Controlled Trials Registry and LILACS databases (January 2000 - February 2017). REVIEW METHODS: Two authors independently identified randomized trials meeting inclusion criteria, assessed their quality and extracted relevant data. Outcomes assessed were the changes in physical function evaluated by scales measuring either the aerobic (meters walked/seconds) or the balance domain (using the Time Up and Go test, in seconds), length of hospital stay (days); and adverse clinical events. We calculated pooled mean differences or Mantel-Haenszel odds ratios and 95% confidence intervals for continuous or dichotomous outcome data and obtained heterogeneity statistics across studies. RESULTS: Thirteen studies, including in total 2703 participants, met our eligibility criteria. Patients in the intervention group showed significant improvement in physical function (aerobic domain), reduced length of stay and a reduction of pulmonary embolism. CONCLUSION: Patients and health providers should consider a course of therapy that enhances the functional capacity of medical patients during hospitalization. This article is protected by copyright. All rights reserved.

Expert commentary

Unplanned hospital admissions for older people can often lead to prolonged periods of reduced mobility and functional decline, either as a result of ill health, subsequent treatment or constraints of the hospital environment.

This review confirms the importance of maintaining patients’ mobility and function during acute hospital admissions through targeted programmes of mobilisation and exercise. Mobility is frequently viewed as the domain of physiotherapists but promoting independence in the hospital should be a multi-disciplinary endeavour and embedded into ward culture and practice.

Alison Cowley, Senior Physiotherapist and NIHR Clinical Doctoral Research Fellow, Nottingham University Hospital NHS Trust

The commentator declares no conflicting interests

Expert commentary

This research offers some evidence to support keeping people in hospital as active as possible. Mobilisation covered a wide range of interventions in this review from exercise groups to individualised walking programmes for a varied group of patients. Pooled data showed improvement in aerobic function and balance and a reduction in hospital length of stay and recurrence of pulmonary embolism.

These results suggest that simple measures such as walking and other functional activities should be taken to keep people admitted to hospital for medical treatment as active as possible. They also offer support for initiatives such as #EndPJparalysis which is widely gaining momentum in the UK and abroad, to allow patients to get dressed and be as active as possible while in hospital.

Dr Helen Fiddler, Principal Lecturer, Academic Lead Physiotherapy, University of Brighton

The commentator declares no conflicting interests