MOBILITY IS MEDICINE

Loretta Schoen Dillon, PT, DPT, MSDirector of Clinical Education and Clinical Associate ProfessorUTEP Physical Therapy Program

OBJECTIVESAt the end of this presentation, the participant will:1. Recall fall related injury statistics and assessment of

fall risk of hospitalized patients.2. Recall negative effects of bed rest.3. Identify risk of hospital associated disability with

various patient cases.4. Compare/contrast Medicare reimbursement issues

related to various patient cases.5. Recognize the need for skilled physical therapy

services in various healthcare settings.6. Weigh risks and benefits of mobility in acute care for

various patient cases.7. Formulate an outline to propose a “Mobility is

Medicine” program in the participant’s work setting.

BACKGROUND Falls and resultant injuries Acute care hospitals and long term care

facilities Nursing to patient ratios Patient acuity The Joint Commission rules Medicare regulations and payment for

performance Lack of education on importance of mobility

Results in: “Hospital associated disability”

How can we change our current practice settings to understand that

FALLS1,2

Unintentional fall are the most common cause of non-fatal injuries in people > 65 years old

Fall-related injuries are most common cause of accidental death in people > 65 years old (41 deaths per 100,000)

In 2010, direct medical costs of falls was $30 billion

20-30% of older adult fallers sustain, lacerations, hip or other bone fractures, or head trauma

Fear of falling leads to further decline and increased risk of falling

REGULATORY RESPONSE TO FALLERS

Fall Risk in acute or long term care settings Fall risk assessments Putting fear in patients

The Joint Commission Medicare American Hospital Association Positive hospital strategies

Avoid bed rest orders Low-low beds3

Reducing preventable falls while increasing mobility4

Negative hospital strategies

MEDICARE PAY FOR PERFORMANCE5

Payment for “non-performance” since 2007, “fall from a bed”

Care coordination/patient safety Screening for falls “Older people reporting a fall or considered at

risk of falling should be observed for balance and gait deficits and considered for their ability to benefit from interventions to improve strength and balance”

NEGATIVE EFFECTS OF BED REST6,PP269-271

Multisystem sequelae of bed rest have been documented for > 60 years Cardiopulmonary and cardiovascular systems

Down-regulation of O2 transport Loss of fluid-volume and pressure regulating

mechanisms Loss of plasma volume Risk of DVT

Musculoskeletal system Muscle and skeletal atrophy Discoordination and balance

Psychological effects Other systems: Neurological, GI, and GU

BOTTOM LINE: Bed rest should be prescribed as judiciously as medication

POSITIVE HOSPITAL STRATEGIES

Accurate fall risk assessment Intrinsic factors

Medications Muscle strength Coordination and balance Medical diagnoses Cognitive status

Extrinsic factors Accessibility to the bathroom Ambulatory aids Other DME Lighting Adequate nursing and ancillary staff

HOSPITAL ASSOCIATED DISABILITY7

Gill et al studied the relationship between hospitalization and restricted activity from 1998 – 2003

Participants were members of the Precipitating Events Project, a study of 745 persons aged 70 years or older, who were not disabled in 4 essential ADLs

Data were collected on gait speed, cognitive status, depressive symptoms and chronic conditions: hypertension, myocardial infarction, heart failure, etc. fractures, amputations, cancer, etc.

Fraility defined by gait speed

HOSPITAL ASSOCIATED DISABILITY7

Results: During 5-year follow up, disability developed

among 55.3% of participants. Physically frail were more likely to develop

disability Hospital admissions for falls were most likely to

lead to disability Conclusion:

Illnesses and injuries leading to either hospitalization or restricted activity represent important sources of disability for older persons living in the community, regardless of the presence of physical frailty.

HOSPITAL ASSOCIATED DISABILITY8

Volpato et al identified demographic, clinical, and biological characteristics of older nondisabled patients who develop new disability in BADL during medical illnesses requiring hospitalization.

At discharge 113 patients (6.7%) presented new BADL disability. Functional decline was strongly related to patients’ age and preadmission IADL status. Multivariate analysis revealed older age, LTC residency, low body mass index, acute stroke, high level of comorbidities, polypharmacotherapy, cognitive decline, and history of fall in the previous year were independent and significant predictors of BADL disability.

HOSPITAL ASSOCIATED DISABILITY9

o Ettinger commentary in JAMAo 7.4% of Medicare beneficiaries who where

hospitalized in 2008 experienced preventable adverse events including the loss of independence and/or the inability to perform self-care functions (ADLs).

o Quality of life and sustainability of independence are not measured as outcomes of care.

o Risk factors for the hospital-associated disability are advanced age, existing dependence in ADLs, physical frailty, cognitive impairment, low albumin level, and acute stroke or metastatic cancer.

HOSPITAL ASSOCIATED DISABILITY9-11

• Hospital environment may contribute to physical disability, patients should be encouraged to ambulate with sufficient supervision.

• Clinicians should assess ADLs in all older patients at admissions and during hospitalization.

• When is it time to call in:

PHYSICAL THERAPISTS (PTS)

PTs earn entry level doctoral degrees and must pass a national licensing exam to practice. State licensure is required in each state in which a physical therapist practices.

PTs help patients reduce pain and improve or restore mobility.

PTs examine each individual and develop a plan, using treatment techniques to promote the ability to move, reduce pain, restore function, and prevent disability.

PTs provide care for people in a variety of settings, including hospitals, private practices, outpatient clinics, home health agencies, schools, sports and fitness facilities, work settings, and nursing homes.

PHYSICAL THERAPY

Physical Therapists and Physical Therapist Assistants are NOT: Massage therapists Moving companies (ie transfer dependent

patients in and out of bed) Walking companies (ie ambulate patients who do

not require skilled care) Physical Therapists and Physical Therapist

Assistants DO: Provide skilled interventions to assist patients to

achieve their goals Provide assessments to plan the transition to the

next level of care

PATIENT CASES Mrs. Gonzalez is an 80 y/o F presented to the ED

with AMS. She was admitted to the hospital with pneumonia and a UTI. Prior to admission she lived alone and was independent in all BADL including ambulation without an assistive device. She is 5’6” and weighs 160lbs (BMI= 25.8). PMH of HTN, hyperlipidemia, and DM II. Home medications include atenolol, Zocor, and insulin. New medication includes Levaquin.

The nursing screen yielded this patient as a “fall risk”.

Does PT need to be consulted? (Think about effects of medications on this patient, BMI and co-morbidities)

PATIENT CASES

Pt is a 65 y/o M who fell while intoxicated and sustained minor head trauma without any neurological sequalae. He is admitted for observation through the ED. PMH includes hepatitis C and HTN. Home medications include lisinopril and metoprolol. Prior to admission, pt was independent in all BADL and IADL including driving. He still works full time as an attorney.

Does PT need to be consulted?

SCREENS FOR FALL RISK12

Rehabilitation Measures Database12: Timed up and Go Dynamic Gait Index Berg Balance Scale Tinneti POMA Five Times Sit to Stand

Nursing looks at a variety of factors on admission in various settings STRATIFY Hendrich II Fall Risk Model Morse Fall Scale

RISK V. BENEFIT

Risks of mobilizing patients (must be hemodynamically stable) Injury Lines and tubes Embolus

Benefits of mobilizing patients: Prevent DVT13

Improve pulmonary function6

Improve patient affect6

Improve overall strength, ROM, and endurance6

INTERVENTIONS TO PREPARE PATIENTS FOR MOBILIZATION

Respiratory therapy Beds that convert to chair positions Equipment to transfer patients out of bed Bed exercises (trunk and extremity)14

TED hose and/or abdominal binders Head of bed elevation Proning

PATIENT CASES

Pt is a 72 y /o F who lives alone and was found by a neighbor to be unconscious in the front yard. She was admitted to the hospital to ICU. She has multiple co-morbidities and developed acute respiratory distress requiring intubation. Two weeks later she has been stabilized and is now on telemetry. She has contracted C difficile and has now been bedbound essentially for 2 weeks. The ICU staff did transfer her bed to chair on 2 occasions, but pt did not tolerate upright postures and demonstrated orthostatic hypotensive events. PT has now been consulted. What are some interventions that might have prevented this patient being in her current condition?

PATIENT CASE15

Pt is a 68 y/o M with end stage renal disease requiring hemodialysis three times a week. PMH includes DM II, HTN, OA, s/p MI 5 years ago with stent placement, and polypharmacy to manage all of his conditions. He uses a front wheeled walker when ambulating outside the home and doesn’t believe in exercising. He is very deconditioned and has no energy after dialysis. He feels he is becoming more of a burden on his 2 sons who are his primary caregivers.

What can we do with him to improve his quality of life?

HEALTH LITERACY16

National Literacy Act of 1991 defined literacy as “an individual’s ability to read, write, and speak in English, and compute and solve problems at levels of proficiency necessary to function on the job and in society, to achieve one’s goals, and develop one’s knowledge and potential.”

Limited health literacy and health outcomes Cultural differences Interpersonal communication Social interaction Does education lead to behavioral change?

DEVELOP YOUR PROGRAM

Group work to formulate an outline to propose a MOBILITY IS MEDICINE program in your work setting.

REFERENCES1. Currie L. Fall and Injury Prevention in Patient Safety and Quality: An Evidence-Based

Handbook for Nurses. Agency for Healthcare Research and Quality website, http://www.ahrq.gov/professionals/clinicians- roviders/resources/nursing/resources/nurseshdbk/CurrieL_FIP.pdf Accessed August 5, 2013.

2. Falls Among Older Adults: An Overview. Centers for Disease Control and Prevention website. http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html Accessed August 5, 2013

3. Barker A, Kamar J, Tyndall T, Hill K. Reducing serious fall-related injuries in acute hospitals: are low-low beds a critical success factor? J Adv Nurs. 2013 69(1):112-21. doi: 10.1111/j.1365-2648.2012.05997.x. Epub 2012 Mar 27.

4. American Hospital Association website. Injuries from falls and Immobility. http://www.hret-hen.org/index.php?option=com_content&view=article&id=5&Itemid=130. Accessed August 5, 2013.

5. Accountable Care Organization 2013 Program Analysis Quality Performance Standards Narrative Measure Specifications. CMS website. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/ACO-NarrativeMeasures-Specs.pdf Accessed August 7, 2013.

6. Dean E. Mobilization and Exercise in Frownfelter D, Dean E. Cardiovascular and Pulmonary Physical Therapy: Evidence and Practice. 4th ed. Mosby Elsevier. St Louis, MO. 2006.

7. Gill TM, Allore HG, Holford T. R., Guo Z, Hospitalization, restricted activity, and the development of disability among older persons. JAMA, 2004;292 (17):2115-2124.

8. Volpato S, Onder G, Cavalieri M, et al. Characteristics of nondisabled older patients developing new disability associated with medical illnesses and hospitalization. Soc Gen Intern Med. 2007;22:668-674. doi: 10.1007/s11606-007-0152-1.

REFERENCES9. Ettinger W. Can hospitalization-associated disability be prevented? JAMA. 2011; 306

(16):1800-1801.

10. Covinsky KE, Pierluissi E, Johnston CB. Hospitalization-associated disability: “she was probably able to ambulate, but I’m not sure.” JAMA. 2011;306(16):1782-1793.

11. Gill TM, Allore HG, Gahbauer EA, Murphy TE. Change in disability after hospitalization or restricted activity in older persons. JAMA. 2010;304(17):1919-1928.

12. Rehabilitation Measures Database. http://www.rehabmeasures.org/default.aspx. Accessed August 8, 2013.

13. Gay V, Hamilton R, Heiskell S, Sparks A.M. Influence of bedrest or ambulation In the clinical treatment of acute deep vein thrombosis on patient outcomes: a review and synthesis of the literature. Medsurg Nursing 2009;18:293-299.

14. Miokovic T, Armbrecht G, Felsenberg D, Belavý DL. Differential atrophy of the postero-lateral hip musculature during prolonged bed rest and the influence of exercise countermeasures. J Appl Physiol. 2011;110:926-934. doi: 10.1152/japplphysiol.01105.2010

15. Lo D, Chiu E, Jassal SV. A prospective pilot study to measure changes in functional status associated with hospitalization in elderly dialysis-dependent patients. Am J Kidney Dis. 2008;52(5):956-961. doi: 10.1053/j.ajkd.2008.04.010

16. Nemmers T.M, Jorge M, Leahy T, Health literacy and aging: an overview for rehabilitation professionals. Topics in Geriatric Rehabilitation. 2013;29:79-88. doi: 10.1097/TGR.0b013e31827e4820

 

Contact Information:Loretta Dillon, PT, DPT, MS

ldillon@utep.edu915-747-8215