Getting older patients moving during hospitalization can improve outcomes, but nurses have many other responsibilities that often take precedence. Realizing that dedicated mobility technicians could help solve this problem, Cleveland Clinic conducted a pilot study to test whether training patient care nursing assistants (PCNAs) to focus on early mobilization could get medical inpatients ages 60 years and older to take more steps.
The concept of mobility technicians, while new, follows a pattern in hospital care, said Michael B. Rothberg, MD, MPH, director for the health system's Center for Value-Based Care Research. “We got orderlies so that nurses don't have to wheel patients to X-ray and to their various tests, and we have nursing assistants who help take the vital signs. . . . It's kind of a natural progression, but we really need to demonstrate the value that it brings before hospitals will take it on widely,” he said.
How it works
The hospital's physical therapy team trained the PCNAs, who have no specific degrees or certification, to be mobility technicians in one four hour-session. They were taught safe handling techniques, including transferring and assisting patients with ambulation. The study enrolled patients with an Activity Measure for Post-Acute Care Inpatient Basic Mobility “six-clicks” score of 16 to 20, who have about a 50% chance of going to a skilled nursing facility after discharge. “These are the patients that we think are going to give us the most return on our investment,” Dr. Rothberg said.
The goal was for the mobility technicians to visit medical patients who had been evaluated by a physical therapist and try to get them moving three times per day in accordance with a recommended ambulation protocol. This involved four exercise levels: sitting, standing, walking, and climbing stairs. “But we don't actually know the right dose,” Dr. Rothberg noted. “We don't know how much you need to walk in the hospital to preserve your function.”
Fifty patients were randomized to be seen by the mobility technicians and were compared to 52 patients receiving usual care (i.e., not seen by the mobility technicians but not otherwise restricted in nursing's baseline ability to execute the physical therapy team's ambulation recommendations). Each patient's activity was measured with a wearable fitness tracker.
On average, 56% of mobility technicians' attempts to ambulate patients were successful, according to results published in the May 2019 Journal of Hospital Medicine. Patients in the intervention group took more steps than those in the control group in both the intention-to-treat analysis (994 vs. 668 steps) and the per protocol analysis (1,182 vs. 726 steps). In a retrospective analysis, the researchers found that patients who took 400 or more steps were more likely to be discharged home than those who took fewer than 400 steps (71% vs. 46%).
When the study began, the mobility technicians were only working five days a week. “There were too many patients who were missing their intervention over the weekend, or we couldn't enroll them because they came on the weekend, so we realized that we really needed to do it seven days a week,” said Dr. Rothberg. In addition, due to staffing shortages, the technicians were pulled away from their mobility work to do other tasks. “Early on in the study, the nurse managers just saw them as PCNAs . . . but over time, when we realized that was happening, we worked with the nurse managers to change it,” he said.
Since the pilot study ended, the mobility technicians are no longer being used at the hospital. But using lessons learned from this pilot study, Dr. Rothberg has his eyes set on an even bigger trial. His team has applied for a grant to study the intervention in 3,000 patients ages 65 years and older at five hospitals to assess potential effects on outcomes such as falls, admissions to skilled nursing facilities, length of stay, and total cost of care. “The goal of this study was to inform that study, to be able to say we know what the intervention is, and we know that we can do it,” he said.
Words of wisdom
The intervention is generalizable in that a hospital could feasibly do it, but the true extent of the benefit remains unknown, said Dr. Rothberg. “There's never been a really large study, so we really don't know what the impact is going to be,” he said. “That's why we want so much to be able to study this in a large, prospective, randomized trial.”