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October 25, 2014

Every day is a moving day

Reuel S. Amdur

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Staying in bed is dangerous to your health. That was the theme of a recent presentation at the Civic Campus of the Ottawa Hospital.

Dr. Barbara Power and physiotherapist Vicki Thomson were the main presenters, discussing a demonstration research project at the hospital aimed at promoting greater mobility for elderly acute care patients. 

It is widely recognized that too many elderly are kept in acute care beds when they should be elsewhere. The presentation began with a quotation from an article by Dr. R.A.J. Asher in the British Medical Journal from 1947:

“…rest in bed is anatomically, physiologically and psychologically unsound.  Look at a patient lying long in bed.  What a pathetic picture he makes!  The blood clotting in his veins, the lime draining from his bones, the scybala (hardened masses of feces) stacking up in his colon, the flesh rotting from his seat, the urine leaking from his distended bladder and the spirit evaporating from his soul.”

Asher addressed many but not all of the pertinent problems. 

He addressed blood clots, brittle bones, constipation, bed sores, incontinence, and apathy.  Too much immobility can result in functional decline as well as delirium.  Asher might well have added other problems to his list, such as decreased lung volume and clogging of mucous, to name just two.

Ottawa Civic hospital is working to increase acute care patient mobility in a way similar to that in which it addresses hand washing.  It is common knowledge that hand washing in hospitals is essential to prevent the spread of infections, and the Civic like many other institutions promotes hand washing by automated reporting.  Similarly, this project involves recording instances of patient mobilization, but there is not a standard way in which this recording is to take place.

Problems were identified, particularly by audience participants.  The big issue is that of time, not only in getting the patient up and about but also in the recording.  Where should it be reported?  One more item for the patient’s chart?  And who should assist in patient mobility?  Volunteers?  The use of volunteers raises other issues.

The first question is where the volunteers are to come from, in helping numbers of more or less immobile seniors.  Another is the issue of liability in case of mishap. 

Audience reaction indicated that a mobilization program, including recording, is just one more demand on a harried staff.  Instead, it was suggested, the program would not mean a need for increased staff but rather a change in the culture of the hospital.  That viewpoint was simply not accepted by those present.

Just what is entailed in mobilizing patients?  The standard is that each patient should be moving at least three times a day.  A dietitian wondered how this applied to her, and the response was that she could try to get the patient to sit up to eat, rather than lying down. 

Early mobilization has been identified in various studies as having positive effects, decreasing length of stay, shortening length of delirium, accelerating return to independent functioning, decreasing the rate of depression, and accelerating rate of discharge home.  The importance of the last item is the reason that hospitals emphasize getting surgery patients out of bed and moving around as quickly as possible after an operation.

While the session addressed a mobility program for hospitals, quite clearly the same issues arise in long-term care facilities and even in home care.  These settings face the same issues of availability of staff and time.  If mobility is not promoted in these other settings, the results will be the same as in the hospital setting.  And long-term care patients and home care patients will be more likely to end up in hospital emergency departments and in hospital acute care.

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