A patient’s mobility status af-fects treatment, handlingand transfer decisions, and

potential outcomes (includingfalls). Hospital patients spend mostof their time in bed—sometimescoping with inadvertent negativeeffects of immobility. Assessing apatient’s mobility status is crucial,especially for evaluating the riskof falling. Yet no valid, easy-to-administer bedside mobility as-sessment tool exists for nursesworking in acute-care settings.Various safe patient handling

and mobility (SPHM) technologiesallow safe transfer and mobiliza-tion of patients while permittingmaximum patient participationand weight-bearing (if indicated).A mobility assessment helps identi-fy the SPHM technology needed toensure safe activities while takingthe guesswork and uncertainty outof deciding which SPHM technolo-gy is right for which patient. Because mobility is so impor-

tant during hospitalization, mem-bers of a Banner Health multidisci-plinary SPHM team determinednurses should take a more activerole in assessing and managingpatient mobility. We concluded itwas crucial to develop and vali-date a tool that nurses can useeasily at the bedside to assess apatient’s mobility level and the

need for SPHM technology. Forboth patient and staff safety, a pa-tient’s mobility level must be linkedwith use of SPHM technology.When used consistently, appropri-ate technology reduces the risk offalls and other adverse patient out-comes associated with immobility.(See The link between patient im-mobility and staff injuries.)

Communication barriers Historically, mobility assessments

and management have been un-der the purview of physical thera-pists (PTs) through consultations.But the entire healthcare teamneeds to address patient mobility.Nurses conduct continual surveil-lance of patients and their pro -gress, but typically they haven’tperformed consistent, validatedmobility assessments. Instead,they’ve relied on therapy servicesto determine the patient’s mobilitylevel and management.

www.AmericanNurseToday.com September 2014 Current Topics in Safe Patient Handling and Mobility 13

Implementing amobility assessmenttool for nurses A nurse-driven assessment tool reveals the patient’smobility level and guides SPHM technology choices. By Teresa Boynton, MS, OTR, CSPHP; Lesly Kelly, PhD, RN; and Amber Perez, LPN, BBA, CSPHP

In many cases, though, a PT’sassessment doesn’t translate tomeaningful actionable items fornurses. What’s more, PTs don’t al-ways adequately communicate apatient’s SPHM needs to otherhealthcare team members. For ex-ample, confusion surrounds termi-nology typically used by PTs, suchas numeric mobility levels (1+, 2+,indicating a one-person or two-person assist, respectively) as wellas ranges (minimum, moderate, ormaximum assist by one or morehealthcare workers). Also, PTs areconsulted only for a limited num-ber of patients and at differentpoints during the hospital stay.Nurses, for their part, aren’ttrained in skilled therapy tech-niques and may be ill prepared tomobilize patients safely duringroutine daily activities. In addition to communicating

potential risk to other healthcareteam members, mobility assess-ment can identify technology need-

ed to perform SPHM. Especially ifPTs aren’t available, nurses mustrely on their own judgment tomove and mobilize patients safely.But they may be uncertain as towhich equipment to use for whichpatients. While a total lift may beused with many patients, such alift doesn’t maximize the patient’smobility potential.

Current mobilityassessment options Although tools to assess mobilityand guide SPHM technology selec-tion are used in hospitals, their val-ue for the bedside nurse may belimited or inappropriate with manypatients in acute-care settings.SPHM algorithms from the Depart-ment of Veterans Affairs have beenvaluable as training and decision-making tools in determining whichSPHM technology to consider forspecific tasks. But these can behard to use at the bedside. Also,they assume the patient’s mobilitystatus is known and don’t providequick guidance in determining apatient’s overall mobility level.(See Limitations of common mobili-ty assessment tools.)

14 Current Topics in Safe Patient Handling and Mobility September 2014 www.AmericanNurseToday.com

The link between patient immobility and staffinjuries Patient immobility poses the risk of injury to healthcare workers. Nurse workloads continue torise as patient acuity levels increase and hospital stays lengthen. This situation increases pa-tients’ dependence on nurses for assistance with their mobility needs.

What’s more, nursing staff frequently rely on the patient or a family member to report thepatient’s ability to stand, transfer, and ambulate. But this information can be unreliable, espe-cially if the patient has cognitive impairment related to the diagnosis or medications or if he orshe has experienced unrecognized decreased mobility and deconditioning from the disease orinjury that necessitated hospitalization.

To decrease the risk of caregiver injury, nurses should assess patient mobility and use safepatient handling and mobility (SPHM) technology.

Limitations of common mobilityassessment tools Several of the mobility assessment tools discussed below already are in use, buteach has certain drawbacks.

The Timed Get Up and Go Test starts by havingthe patient stand up from an armchair, walk 3meters, turn, walk back to the chair, and sit down.But it gives no guidance on what to do if the pa-tient can’t maintain seated balance, bear weight,or stand and walk.

The Quick 5 Bedside Guide tool, developed bya registered nurse and physical therapist (PT),was the basis for a research project on what be-came known as the Quick 3. This tool takes thepatient through three functional tasks but doesn’tfully address patient limitations. Nor does it rec-ognize weight-bearing limitations or address theissues or abilities of an ambulatory patient. Also,it provides only limited recommendations forSPHM technology.

The Egress test, also developed by a PT, is usedin hospital settings. It starts with the patient per-forming three repetitions of sit-to-stand, at thebedside, marching in place, and advance step andreturn with each foot. But it’s tailored to PTs anddoesn’t address how the patient performs bed mobility or comes to a standing po-sition. Also, it gives only limited guidance for nurses on use of SPHM technologyand isn’t appropriate for certain patients (such as those unable to weight bear onone or both legs).

Nurses aren’t trained in

skilled therapytechniques and may be ill

prepared to mobilize patients

safely during routine daily

activities.

Banner MobilityAssessment Tool At Banner Health, we developedthe Banner Mobility AssessmentTool (BMAT) to be used as a

nurse-driven bedside assessmentof patient mobility. It walks thepatient through a four-step func-tional task list and identifies themobility level the patient can

achieve (such as mobility level1). Then it guides the nurse to therecommended SPHM technologyneeded to safely lift, transfer,and mobilize the patient. (See

www.AmericanNurseToday.com September 2014 Current Topics in Safe Patient Handling and Mobility 15

Banner Mobility Assessment Tool for nurses Nurses have found that the Banner Mobility Assessment Tool (BMAT) is an effective resource for performing a bedside assessment of patientmobility.

Fail = Choose most appropriateTest Task Response equipment/device(s) Pass

Assessment Sit and shake: From a semi-reclined Sit: Patient is able to follow MOBILITY LEVEL 1 Passed Assessment Level 1 position, ask patient to sit upright and commands, has some trunk strength; • Use total lift with sling and/or Level 1 = Proceed Assessment of: rotate* to a seated position at side caregivers may be able to try weight- repositioning sheet and/or straps. with Assessment • Trunk strength of bed; may use bedrail. bearing if patient is able to maintain • Use lateral transfer devices, such Level 2.• Seated balance Note patient’s ability to maintain seated balance longer than 2 minutes as roll board, friction-reducing

bedside position. (without caregiver assistance). device (slide sheets/tube), or Ask patient to reach out and grab your Shake: Patient has significant upper air-assisted device.hand and shake, making sure patient body strength, awareness of body in Note: If patient has strict bed restreaches across his/her midline. space, and grasp strength. or bilateral non-weight-bearing

restrictions, do not proceed with the assessment; patient is MOBILITY LEVEL 1.

Assessment Stretch and point: With patient in Patient exhibits lower extremity MOBILITY LEVEL 2 Passed Assessment Level 2 seated position at side of bed, have stability, strength and control. • Use total lift for patient unable to Level 2 = Proceed Assessment of: patient place both feet on floor (or stool) May test only one leg and weight- bear on at least one leg. with Assessment • Lower extremity with knees no higher than hips. proceed accordingly (e.g., • Use sit-to-stand lift for patient who Level 3.

strength Ask patient to stretch one leg and stroke patient, patient with can weight-bear on at least one leg.• Stability straighten knee, then bend ankle/flex ankle in cast).

and point toes. If appropriate, repeat with other leg.

Assessment Stand: Ask patient to elevate off bed or Patient exhibits upper and lower MOBILITY LEVEL 3 Passed Assessment Level 3 chair (seated to standing) using assistive extremity stability and strength. • Use non-powered raising/stand aid; Level 3 AND no Assessment of: device (cane, bedrail). May test with weight-bearing default to powered sit-to-stand lift assistive device• Lower extremity Patient should be able to raise buttocks on only one leg and proceed if no stand aid is available. needed = Proceed

strength for off bed and hold for a count of five. May accordingly (e.g., stroke patient, • Use total lift with ambulation with Assessment standing repeat once. patient with ankle in cast). accessories. Level 4.

Note: Consider your patient’s cognitive If any assistive device (cane, • Use assistive device (cane, walker, Consult with ability, including orientation and CAM walker, crutches) is needed, crutches). physical therapist assessment if applicable. patient is Mobility Level 3. Note: Patient passes Assessment Level when needed

3 but requires assistive device to and appropriate. ambulate or cognitive assessmentindicates poor safety awareness; patient is MOBILITY LEVEL 3.

Assessment Walk: Ask patient to march in place at Patient exhibits steady gait and good MOBILITY LEVEL 3 MOBILITY LEVEL 4Level 3 bedside. Then ask patient to advance balance while marching and when If patient shows signs of unsteady gait MODIFIED Assessment of: step and return each foot. stepping forward and backward. or fails Assessment Level 4, refer INDEPENDENCE• Standing balance Patient should display stability while Patient can maneuver necessary turns back to MOBILITY LEVEL 3; Passed = No • Gait performing tasks. for in-room mobility. patient is MOBILITY LEVEL 3. assistance needed

Assess for stability and safety awareness. Patient exhibits safety awareness. to ambulate; use your best clinical judgment to determine need for supervision during ambulation.

Always default to the safest lifting/transfer method (e.g., total lift) if there is any doubt about the patient’s ability to perform the task.

Banner Mobility Assessment Toolfor nurses.)

Implementing BMAT The BMAT was created in our hos-pital’s electronic medical record(EMR) in a way that guides thenurse through the assessmentsteps. Patients are determined tohave a mobility level of 1, 2, 3,or 4 based on whether they passor fail each assessment level. Edu-cational tools and tip sheets areused to train nurses and supportstaff on what technology to consid-er for patients at each level.

Communication tools also areused. For instance, a sign outsidethe patient’s room indicates his orher mobility level, instantly tellinganyone passing by or entering ifthe patient can ambulate inde-pendently or if SPHM technologymust be used. To stay current onthe patient’s mobility status (for in-stance, at handoffs, after proce-dures, with medication changes,or after a potentially tiring therapysession), nurses are expected tocomplete the BMAT on admission,once per shift, and with the pa-tient status changes. The BMAT also is linked to Banner’s fall as-sessment risk in the EMR. Throughout BMAT implementa-

tion, we recognized that identify-ing a patient’s mobility level andfall risk score are pointless unless

appropriate interventions are im-plemented and the outcomes eval-uated. Nurses need to be empow-ered and able to recognize theconnection between these assess-ments and choice of interventions,including SPHM technology. Here’s an example of BMAT in

action at Banner: A 35-year-oldmale was admitted to a surgicalfloor late in the evening. He was6'2" tall and weighed 350 lb(158 kg). He didn’t want to use abedpan, but his nurse wasn’t com-fortable getting him up to use thebathroom because he hadn’t beenevaluated by physical therapy,and a PT wasn’t available in theevening. A nurse passing bywho’d used the BMAT (which had-n’t been formally rolled out Ban-ner-wide at that time) came in andassessed the patient; the assess-ment found him at mobility level 3.He was transferred to the toilet us-ing a nonpowered stand aid. Bothpatient and nurse were relievedand happy.

A step in the rightdirectionAs a quick bedside assessmenttool, the BMAT is a step in the rightdirection. It’s part of a broad pro-gram of increased staff awareness,education, and training around pa-tient assessments, preventing staffinjuries and patient falls, andachieving better patient outcomes.Initial evidence from a validationstudy completed at one Banner hos-pital supports the BMAT as a validinstrument for assessing a patient’smobility status at the bedside. As we work toward customizing

actions and interventions to meetindividual patient needs, we contin-ue to evaluate which additional as-sessment components or fall inter-ventions or precautions are needed

or require greater focus. Althoughwe know nurses should be more in-volved in assessing mobility thanthey have been historically, we rec-ognize the value of involving andcommunicating effectively with allmembers of a good interdiscipli-nary team to help reduce patientfalls and staff injuries caused bypatient handling. 8

Selected referencesDionne M. Practice Management: Stand and de-liver. Physical Therapy Products. March 2005.www.ptproductsonline.com/2005/03/stand-and-deliver/. Accessed June 30, 2014.

Hook ML, Devine EC, Lang NM. Using a com-puterized fall risk assessment process to tailorinterventions in acute care. In: Henriksen K, Bat-tles JB, Keyes MA, Grady ML, eds. Advances inPatient Safety: New Directions and AlternativeApproaches; vol 1. Assessment. AHRQ Publica-tion No. 08-0034. Rockville, MD: Agency for Healthcare Research and Quality; 2008.www.ncbi.nlm.nih.gov/books/NBK43610. Ac-cessed July 10, 2014.

Mathias S, Nayak US, Isaacs B. Balance in eld-erly patients: the “get-up and go” test. ArchPhys Med Rehabil. 1986;67(6):387-9.

Oliver D, Healey F. Falls risk prediction tools forhospital inpatients: do they work? Nurs Times.2009;105(7):18-21.

Oliver D, Healey F, Haines TP. Preventing fallsand fall-related injuries in hospitals. Clin GeriatrMed. 2010;26(4):645-92.

Nelson AL. Safe patient handling and move-ment: A guide for nurses and other health careproviders. New York, NY: Springer PublishingCompany, Inc.; 2006. www.springerpub.com/samples/9780826163639_chapter.pdf. Ac-cessed June 30, 2014.

Nelson A, Harwood KJ, Tracey CA, Dunn KL.Myths and facts about safe patient handling inrehabilitation. Rehabil Nurs. 2008;33(1):10-7.

Wright B, Murphy J. “Quick-5 Bedside” Guide.Franklin, MA: Liko, Inc.; 2005.

Teresa Boynton is an injury prevention andworkers’ compensation consultant, ergonomicsspecialist, and certified safe patient handlingprofessional for Risk Management at BannerHealth, Western Region, based in Greeley, Col-orado. Lesly Kelly is the RN clinical researchprogram director for Banner Good SamaritanMedical Center in Phoenix, Arizona. AmberPerez is a safe patient handling clinical con-sultant for Handicare North America based inPhoenix, Arizona.

16 Current Topics in Safe Patient Handling and Mobility September 2014 www.AmericanNurseToday.com

To stay current on the patient’s

mobility status nurses are

expected to complete the BMAT on

admission, once per shift, and with

the patient status changes.