BY: MICHELLE MOCCIA, DNP, ANP-BC, CCRN and BELINDA DOKIC, CPHT, MHA
Preventing injuries from falls has been a flagship topic in health care quality improvement and patient safety for nearly two decades. The complications that can follow injurious falls in older adults can cause many adverse outcomes, including death. This reality, along with associated programming and reporting requirements, has kept the prevention of falls front and center across the health care continuum. Although everyone can agree that falls are to be avoided, the Age-Friendly Health Systems initiative is working to broaden the conversation by emphasizing the physical and mental health benefits associated with mobility and by encouraging greater mobility for older adults in conjunction with falls prevention.
The Age-Friendly Health Systems initiative is funded by The John A. Hartford Foundation and led by the Institute for Healthcare Improvement, in partnership with the American Hospital Association and the Catholic Health Association. The initiative encourages clinicians and caregivers to focus on the "Four Ms" in caring for older adults: what Matters, Medications, Mentation and Mobility.
Mobility was included as one of the four Ms because of its innumerable benefits to the health outcomes of older adults, including improved sleep, mood and appetite; decreased pain; reduced hospital length of stay and need for post-acute care; and improved heart, lung and brain function. Increased mobility also interacts and improves outcomes related to the other four Ms — mentation, medication and what matters — because so many health and life goals are tied to mobility.
Trinity Health's St. Mary Mercy Livonia, a 304-bed, acute care community hospital in Livonia, Michigan, is one of the sites of care involved in piloting the Age-Friendly Health System initiative. St. Mary Mercy has been a NICHE member (Nurses Improving Care for Healthsystem Elders) for many years, and it was attracted to the Age-Friendly Health Systems initiative due to its broad reach, ambitious goal and how it complemented both internal and external activities at the hospital. The Age-Friendly Health Systems work aligned very well with an organizational initiative to decrease the number of discharges to skilled-nursing facilities and improve skilled-nursing facility length of stay.
The quality work group, an interdisciplinary team comprising medical leadership, nursing, case management, and rehabilitation services, was convened in 2016 at St. Mary Mercy to address the goals of decreasing discharges to skilled nursing facilities and reducing length of stay when transition to a skilled nursing facility is required. The group hypothesized that mobilizing appropriate patients sooner and more frequently would help to speed healing, reduce hospital length of stay and decrease readmissions.
The quality work group worked in three phases, starting with an observation unit, then the medical-surgical unit, then moving hospitalwide. Before starting the first phase, the team created an evidence-based mobility protocol to be tested, refined and implemented in each unit. The protocol is:
All patients will have orthostatic blood pressure assessments completed at the beginning of each shift to assure their ability to walk or move.
All patients will be assisted to the chair in their room for all meals and to the bathroom by care team staff.
Other "move" strategies included ambulation aide assistance and encouragement for the patient to walk one to two times in the hallway. Staff measured — and celebrated — distances achieved.
The pilot site on the observation unit implemented the protocol by adding additional, full-time ambulation aides to get patients up and moving during their stay. The ambulation aides received training from physical therapists and worked during extended daytime hours in order to be able to engage with patients' family members.
The second site, the medical-surgical unit, took a slightly different approach, focusing on increasing the number of patient-care assistants so that among their other patient-care responsibilities, they could encourage and help patients to get up and move. This site also gave patient-care assistants education about why mobility is important for elderly patients and trained them on how to help patients walk and move safely.
As aides and assistants worked with patients on mobility, they made a point of "interviewing" to find out what, in the patients' minds, really mattered. Those conversations resulted in a number of care enhancements, but one thing came out loud and clear: Patients did not like trying to walk around in open-backed hospital gowns.
Staff gave patients shorts to wear under the gown and then collected reactions. Did the shorts make them more comfortable about walking in the halls? Was there any way to improve the shorts' design?
The result: all patients on both units receive a pair of "walking shorts" designed, from fabric to pocket location, by patient feedback.
The team also adopted the mnemonic MOVE — Mobility Optimizes Virtually Everything —that they shared with patients, clinicians and staff alike. MOVE appeared on stickers, buttons, charts and even M&Ms. Units customized MOVE tools to encourage patient mobility such as laminated flip charts outlining goals, posters and distance markers on the corridor walls so patients could see how far they were walking.
Although the team at St. Mary Mercy is still working on validating data collected around average length of stay and patient satisfaction, the initial pre- and post-measurement of the mobility program's results look promising. They indicate a statistically significant improvement in the percent of patients who were discharged to home or self-care and suffered no falls with injury.
MICHELLE MOCCIA is program director, senior emergency center, St. Mary Mercy Livonia Hospital, Livonia, Michigan.
BELINDA DOKIC is regional ACO/CIN program manager, Saint Joseph Mercy Health System, Livonia, Michigan.
NOTE: The John A. Hartford Foundation and the Institute for Healthcare Improvement are partnering on the Age-Friendly Health Systems initiative. Five U.S. health systems are testing and scaling up the prototype model in their organizations, which include three Catholic ministries: Ascension, Trinity Health and Providence St. Joseph Health. For more information and to follow initiative updates, visit the Institute for Healthcare Improvement's website, ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems or email [email protected].