Mobility is Medicine


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Mobility is Medicine
Loretta Schoen Dillon, PT, DPT, MS
Director of Clinical Education and Clinical Associate Professor
UTEP Physical Therapy Program

Mano y Corazón Binational Conference of Multicultural Health Care Solutions, El Paso, Texas, September 27-28, 2013

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  • Examples include avoiding bed rest orders; instituting a toileting schedule to assure that a patient has help walking to and from the bathroom at regular intervals; frequent walks; frequent reorientation if confused; providing a safe environment including good lighting, a bed that lowers to the floor, appropriate assistive devices, and removing clutter; and reducing drugs that may cause dizziness, drowsiness, or confusion. Devices such as bed and chair alarms that alert staff to a patient’s movement should be used only in combination with interdisciplinary and multi-component responses to avoid the consequences of immobility
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  • Mobility is Medicine

    1. 1. MOBILITY IS MEDICINE Loretta Schoen Dillon, PT, DPT, MS Director of Clinical Education and Clinical Associate Professor UTEP Physical Therapy Program
    2. 2. OBJECTIVES At 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.
    3. 3. 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
    4. 4. 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
    5. 5. 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
    6. 6. 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”
    7. 7. 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
    8. 8. 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
    9. 9. 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
    10. 10. 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.
    11. 11. 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.
    12. 12. HOSPITAL ASSOCIATED DISABILITY9 o Ettinger commentary in JAMA o 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.
    13. 13. 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:
    14. 14. 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.
    15. 15. 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
    16. 16. 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)
    17. 17. 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?
    18. 18. 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
    19. 19. 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
    20. 20. 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
    21. 21. 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
    22. 22. 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?
    23. 23. 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?
    24. 24. DEVELOP YOUR PROGRAM  Group work to formulate an outline to propose a MOBILITY IS MEDICINE program in your work setting.
    25. 25. REFERENCES 1. Currie L. Fall and Injury Prevention in Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Agency for Healthcare Research and Quality website, 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. 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- Accessed August 5, 2013. 5. Accountable Care Organization 2013 Program Analysis Quality Performance Standards Narrative Measure Specifications. CMS website. 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.
    26. 26. REFERENCES 9. 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. 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  
    27. 27. Contact Information: Loretta Dillon, PT, DPT, MS 915-747-8215