1. Nurse Driven Mobility Protocol
Sandy Gandee RN, ACNS-BC
Cristiane Fukuda RN-C, ANP-BC

2. Objectives
Describe the effects of immobilization in the overall health outcomes of hospitalized adults.
Present Northside Hospital Mobility Protocol (PM) “STEP IN”.
Discuss recommendations for successful implementation of a MP.
Review patient outcomes related to the MP implementation in 2 medical-surgical pilot units.

3. The Need for MP Literature review: Our own observations:
Bed rest in hospitalized patients leads to an increase in hospital acquired complications such as venous thrombosis, falls and hospital acquired pneumonia.
There are benefits of an early mobility protocol for ICU patients but comparably little has been published regarding the benefits of mobility for the med-surgical population.
Early mobilization through standardized mobility protocols or programs can improve patient outcomes.
Our own observations:
Pneumonia DSC Program Indicators.
Falls and Readmission data
Evidence of functional decline.

4. Functional Decline
Occurs when a patient is unable to perform activities such as eat, bathe, dress, walk and take medications.
Deconditioning and functional decline from baseline have been found to occur by day 2 of hospital stay in older patients.
One day of bed rest requires 3-5 days to regain strength.
Function does not return to baseline by the time of discharge without aggressive intervention to prevent the loss.
Fischer, S.R., Kue, Y.F., Graham, J.E., Ottenbacher, J.K., & Ostir, G.V. (2011). Early ambulation and length of stay in older adults
hospitalized for acute illness. Archives of Internal Medicine, 170,
Winkelman, C. (2009). Bed rest in health and critical illness. AACN Advanced Critical Care, 20,

5. Functional Decline
Hospitalization poses a risk for altered functional status due to acute illness and decreased mobility
Use of prolonged bed rest.
Physical restraints.
Use of devices such as Foley catheters and intravenous lines.

6. The Impact of Immobility
Affects all systems
Significant effects in 2-3 days
Increases morbidity & mortality
Recovery time measured in months → years
Often overlooked
Days of Immobility
Days of full recovery 18 7 52 14
121 21
300
Slide courtesy of Varsha M. Kanvinde

7. Mobility Protocol Goals “STEP IN”
S: Support independence
T: Train for care at home
E: Encourage ADL
P: Prevent functional decline
I: Interdisciplinary approach
N: No exclusion, no excuses
The Borun Center’s research on ambulation programs had only one criterion for inclusion in the study: the ability to follow a one-step command.
Do not rule out patients with dementia when assessing for mobility programs.
Even those with severe cognitive impairments will participate in the program. NO EXCUSES, NO EXCLUSIONS
The Borun Center (2009). Mobility Decline Prevention. The Borun Center. Retrieved from:
edu/centers/borun/modules/Mobility_decline_prevention/walk1c.htm

8. Assessment of Mobility Level
On admission
Modified Barthel Index (MBI)
Risk to Fall Assessment
“Get-Up-and-Go-Test
Ongoing
On Discharge
MBI
Correlate to the prediction scores and discharge planning
Important to communicate with Case Management about the discharge planning needs

9. Modified Barthel Index (MBI)
Modified Barthel ADL index is a scale used to measure performance in activities of daily living (ADL).
Each performance item is rated on this scale with a given number of points assigned to each level or ranking.
We can use information from caregivers and family members.
Variables addressed in the Barthel scale are:
Chair/bed transfers
Ambulation/ Wheelchair
Stair climbing
Toilet transfers
Bowel control
Bladder control
Bathing
Dressing
Personal hygiene (grooming)
Feeding
MBI was built into EMR

10. MBI Score Interpretation Score Prediction 0-20 21-60 61-90 91-99 100
Total Dependency
21-60
Severe Dependency
61-90
Moderate Dependency
91-99
Slight Dependency
100
Independence
Score
Prediction
Less than 40
Unlikely to go home
Dependent in mobility
Dependent in Self Care (ADLs) 60
Pivotal score where patients move from dependency to assisted independence
If living alone, will probably need a number of community services to cope
More than 85
Likely to be discharged to community living
Independent in transfers and able to walk or use wheelchair independently.
REFERENCES
1. Shah, S., Vanclay, F., & Cooper, B. (1989a). Improving the sensitivity of the Barthel Index for stroke
rehabilitation. Journal of Clinical Epidemiology, 42,
2. Shah, S., & Cooper, B. (1991). Documentation for measuring stroke rehabilitation outcomes.
Australian Medical Records Journal, 21,
3. Shah, S., Cooper, B., & Maas, F. (1992). The Barthel Index and A D L evaluation in stroke
rehabilitation in Australia, Japan, the U K and the U S A. Australian Occupational Therapy Journal,
39,
4. Granger, V., Dewis, L., Peters, W., Sherwood, C., & Barrett, J. (1979). Stroke rehabilitation
analysis of repeated Barthel Index measures. Archives of Physical and Medical
Rehabilitation, 60,
5. Hasselkus, B., (1982). Barthel self-care index and geriatric home care patients. Physical and
Occupational Therapy in Geriatrics, 1,
6. Leonard, R., & McGovern, L. (1992). The Barthel Index in an acute geriatric setting.
American Journal of Occupational Therapy, 39,
Shah, S., Vanclay, F., & Cooper, B. (1989a). Improving the sensitivity of the Barthel Index for stroke rehabilitation. Journal of Clinical Epidemiology, 42,

11. “STEP IN” Mobility Program
Functional Assessment
MBI
Get-up-and-go
Risk to Fall
Level 1
MBI: 0-60 Severe -Total Dependence
Get-up-and-go: 4
- Assist to chair, wheelchair, or neuro chair at least twice a day
- Use mechanical lift system
- Consider PT/OT consult
Level 2
MBI: Slight – Moderate Dependence
Get-up-and-go: 1,3
- Assist to chair, wheelchair, or neuro chair at least twice a day
- Use gait belt
- Ambulate in hallways, at least 2 X a day using a gait belt and or assistive devices (as necessary)
- Monitor for Functional Decline
Level 3
MBI: 100 Independent
Get-up-and-go:0
- Sit up in a chair and ambulate in hallways at least 3 X a day.
- Ambulate with an assistive device, as necessary
- Pedometer to record progress

12. Road Map for Success Getting unit and leadership ready
Getting staff ready
Identifying and managing barriers
Monitoring Outcomes

13. 1. Getting the Unit Ready
Meet leadership to explain components of the program.
Culture change versus a program implementation.
Leadership commitment and follow up with staff daily.
Identification of stakeholders and “Super Users”.
Identification of unique factors related to mobility for the unit patient population.
Equipment Inventory.
Patient education.

14. 2. Getting Staff Ready Education Small Groups Didactic Follow Up
Led by RNs/ PT/OT
Risk of Immobility
Benefits of Mobility
Focus-Function Care
Tools and Resources
Safe Patient Handling
“Hands on” skill session
Follow Up
Daily Huddles
Staff Counseling
“Mobility tips”
Disciplinary action
New Hire Orientation
FCC: Philosophy of care that focuses on attaining and or maintaining patient functional ability
Focus on what patients can do, not the disability
Incorporates mobility and functional skills training on whatever care is given to the patient
It is not a project to be implemented; it is a vision
Resnick,B.; Galik,E.; Boltz,M. Function Focused Care approaches: Literature Review of progress and future possibilities. JAMDA 14(2013)

15. 3. Identifying & Managing Barriers
Unit Assessment
Readiness for change
Patient Population
Resources
Culture
Organization
Roll out time line
Electronic Record Documentation
Concurrent Compliance Reports
Physician support
Resources: Handbook with presentation, paper version of modified barthel with case studies that were discussed in class, PT abbreviations, Leadership roll out handbook. Not on and done. Many paper versions of the Barthel were tweaked to support staff work flow. In addition it had to be modified to work within the character limits of the electronic medical record.

16. Road Map for Success Organization Commitment Unit Commitment
Interdisciplinary Team
Evidenced Based Practice
Engaged Leadership
Unit Champions
Compliance Monitoring
Data Sharing
Outcomes Revealed

17. Hardwiring Identifiy Opportunities for Improvement:
Recognize Success
Focus
IOFI’s
Identifiy Opportunities for Improvement:
Documentation field states “current activity”- often times this field was documented in when techs were taking VS’s. We are currently in process of revising the electronic fields that staff document activity in. Opportunities related to Barthel continue. We want the scoring system to have an option to document the level of activity on the same screen as the barthel score. We also want this level of activity to be viewable in the electronic plan of care. Each opportunity gives us additional opportunities to fine tune the documentation system.

18. 4. Monitoring Outcomes Examples of Outcomes to Measure Length of Stay
Readmission Rates
Fall Rates
Morbidity
Delirium
Sitter Rates
Functional Scores
Discharge Status
Rehab consults

19. Mobility Protocol Pilot Results
Can it Make a Difference?

20. 5 C Mobility Protocol Documentation Compliance Nov 2013 - Dec 2014

21. 5C Falls Rate

22. 5C Aggregate Fall Rate Jan 13- Dec 13 compared to Jan 14 –Dec 14

24. 5 C Length of Stay Pre and Post “STEP IN” Protocol

25. Mobility Documentation Compliance 4W
* November and December data based on a week sample

26. Patient Fall Rates before and after Mobility Protocol - 4W/Cherokee

27. 4W Aggregate Fall Rate July13-Jan14 compared to July14 -Jan15
15% reduction

28. Questions?