Tuesday, September 15, 2009

Bedrest as a danger of hospitalization


There is an important study in the current issue of the Journal of the American Geriatrics Society. This study addresses a rather fundamental question: How do older people spend their time when they are hospitalized? The answer is rather disturbing. They spend the vast majority of time bedbound. The study was led by Cynthia Brown from the Division of Geriatrics at the University of Alabama, Birmingham.

It is well known that hospitalization is a very vulnerable period for older persons. Many elders who are hospitalized for seemingly routine illnesses leave the hospital with a major new disabilty that threatens their ability to live independently. This happens even though the medical problem that resulted in hospitalization is resolved. Most studies suggest that about 1/3 of medical hospitalizations in persons over the age of 70 will result in a major new disability---this risk is over 50% in patients over age 85. Many Geriatricians believe that the type of care provided in the hospital contributes to the development of disability. A chief concern is bedrest. Older people seem to weaken quickly when confined to bed, and a number of studies show rapid loss of muscle mass in elders confined to bed.

Dr. Brown's elegant study asked how older persons spend their time when hospitalized for a medical illness. She attached wireless accelerometers to 45 older patients shortly after their admission. This allowed her to determine how often patients were lying down, sitting, and standing or walking. The subject selection for this study was notable because Dr. Brown only included subjects who should have been mobile. All subjects were walking prior to hospitalization. Even at the time of admission, 78% of subjects were able and willing to walk without assistance. None of the subjects had severe cognitive impairment or delirium.

So, how did subjects spend their time? On an average day elders spent:

  • 83% of their time in bed (20 hours!)
  • 13% sitting (3.1 hours)
  • 4% standing or walking ( 55 minutes)

Again, recall that this study targeted the older patients who were most able to be out of bed.

This study raises fundamental issues about the quality and processes of care for older patients hospitalized with medical illnesses. It seems quite probable that this degree of immobility contributes to the very high rates of disability we see following medical hospitalization in older persons. While this study was done at one hospital, I strongly suspect this pattern is typical of most US hospitals. I believe the results would be similar at my hospital.

As clinicians, we need to think about what we can do to prevent immobility in our older patients. No patient who is capable of sitting should be lying in bed all day. At a minimum, we need to get our patients out of bed and into a chair. We need to think about the restraining effect of devices such as IV poles and urinary catheters, which we know are kept in too long. It is time to make mobilization a key quality of care indicator for hospitals. Accrediting organizations like JCAHO can play a positive role in this. Wouldn't it be great if JCAHO inspectors walked around medical wards and asked why patients were lying in bed?

We also need to be sure that other policies, such as penalizing hospitals for inpatient falls, does not have the unintended consequence of reducing mobility. We also need to accelerate efforts such as Acute Care for Elders Units to redesign the processes of hospital care in older persons.

7 comments:

Not perfect, but His said...

As a Physical Med/Rehab doc, I have often said that we need to order bedrest like a medication rather than assuming it is the standard for what patients will be doing while hospitalized.

Chrissy Kistler said...

Hmm... Good idea, NPBH. I think the standard should be out of bed TID or more, and that you should have to particularly write if you want them to stay in bed.

And of course, go ACE units! Let's not forget, Margarita Sotelo is now staffing the "Ace of Hearts" unit at SFGH, also. It's for the cardiac floor older adults.

Ella Bowman, IU Geriatrics said...

Great summary! On our ACE Unit one of our biggest initiatives is to get the primary team to cancel all the strict bedrest orders, which are rather common! It would be interesting to study whether the ordering of "strict bed rest" has actually increased since the CMS announced its never-events relating to hospital acquired falls. I agree with the others that we treat such orders as rarely necessary, and should be ordered like any medical treatment, with justification of continued use taking place each and every day.

Chrissy Kistler said...

In discussion with Ron Walent, he mentioned that physicians' orders used to require an "activity" level, to which I responded that they still do. However it occurred to me that the standard "ad lib" is in fact not very "lib", that patients aren't at their liberty to just get up and walk around. For one, they're tied down to their IVs or catheters (which have been in place since the ER) or the staff is worried b/c they can't find the pt who might now be AWOL. But wouldn't it be lovely to see a pack (or whatever the collective term for a roaming hoarde of hospital patients is) of patients doing laps around the nursing stations?

Helen Kao said...

Other noteworthy alternatives to hospitalization also need to be considered such as Hospital at Home models in communities and hospital regions with existing networks of physician housecall practices and home health agencies. There are many established models of care which are better than standard hospital care for older adults. We need to advocate for these (ACE, Hospital at Home, HELP, etc.) as a community. Another option I keep thinking about as my parents and friends age and retire (and find themselves needing a new purpose or volunteer activity) would be to recruit seniors to volunteer in hospitals as trained activity leaders, walking partners, etc.

Paula Jacunski said...

How can we prevent elder patients being bedbound? Hire more nursing assistants. The current level of nursing staff has barely enough time to admit and discharge patients and complete medical and hygiene care. And yes, our focus on patient falls definitely decreases a patient's mobility. If one has any risk of falling based on various criteria, the bed alarm goes on or a unit on the chair to let nursing staff know when the patient is moving...pretty soon most of them learn to stay put so they won't set off the ear-splitting alarm. Our hospital physicians already order activity levels. Even when they order "ambulate TID" though, it unfortunately doesn't rise to the top of my priority list as a nurse, trying to get all of the other medical orders completed. Does it need to change...definitely!

Eric Widera said...

Very well stated Paula. It really isn't enough to have a physician order if there is not enough support to back up that order. Out-of-bed TID also becomes a useless order if, as Chrissy stated, we tie patients down with IVs, foleys, and tele monitors. A comprehensive approach (like an ACE unit) is what is really needed, as well as taking into account nurse/patient ratios.