NIRH: getting patients up and moving shortens stay and improves fitness

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 per cent and 65 per cent of older people. This could hasten their loss of physical function and increase de-conditioning. 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 per cent 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 per cent 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 percent 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 per cent) new clots versus 21(13 per cent) treated with usual care (odds ratio [OR] 0.33, 95 per cent 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 per cent of the mobilisation group compared with 44.6 per cent of the control group (OR 0.62, 95 per cent 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?

Overall this review adds evidence from patient interviews that could help healthcare professionals to encourage more effective uptake of exercise in this group. It reinforces existing evidence about the benefits of exercise for people with arthritis with slight improvements in pain and function, indicating how these benefits could be maximised.

Specific suggestions are that rehabilitation programmes could educate people about the causes and potential disease course of osteoarthritis, challenging the belief that exercise causes harm and reassuring people that it is safe and beneficial. The researchers suggest that advice is tailored to each individual patient, managing expectations about the ways in which exercise might improve or worsen their symptoms or leave pain and mobility unchanged.

Physiotherapists already have a role in offering personalised advice and encouragement and this review provides further evidence for them. 

The full NIHR Signal and additional expert commentary was published on 16 April 2019.

Expert view: Chris Tuckett falls prevention practitioner and physiotherapist, Princess Alexandra Hospital NHS Trust

Take medically unwell older people and admit them to an acute hospital and the result is too often deconditioning and a loss of both function and independence. 

This is due, in part, to an innate risk-aversion amongst many healthcare staff, and a fear of patients falling often tops this list of unwanted outcomes.

So it was with great pleasure that I read this NIHR signal that clearly highlights the benefits of patient mobility (better function, reduced length of stay, fewer lung clots) but critically demonstrated no change to the participants’ fall risk.

As clinicians it is incumbent on us all to be aware of the potential benefits and harms of all interventions, and whilst mobilisation is certainly not risk-free (nothing ever is), it is about time we updated our notion of what harm-free care actually means. 

Does it mean doing what makes us feel most comfortable, or does it mean doing what is clinically beneficial for the patient? 

If it is the latter then mobilisation should be the great priority, and as physiotherapists we need to champion this vocally while using the evidence provided by such NIHR signals.

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.