 Hi everybody, I'm Donna Prosser, Chief Clinical Officer with the Patient Safety Movement Foundation. We're here to talk today about mobility management and I'm excited to be joined by Debra Maluski. She's an adjunct professor of physical therapy at Chapman University and she is also a practicing physical therapist. Welcome Debbie. Well hello Donna, it's nice to meet you. Thanks so much for joining. I wonder if you could tell us a little bit about your background. Certainly. I've been practicing as a physical therapist for 29 years. The majority of my patient care experiences have been in acute care hospitals, in acute rehab settings, also in skilled nursing, rehab settings. I do lecture at Chapman University at this time and I am currently practicing at a trauma hospital so I have plenty of experience with patient care. Excellent. All right, well then let's just get right to the questions then. I wonder if you could start by telling us, you know, why is it that mobility is so important and what is the relationship to other quality and safety outcomes? Well, mobility obviously is critical to our well-being. There have been many, many studies have shown that bed rest negatively impacts all of our body systems. That's not new knowledge. Mobility sometimes is misinterpreted as more like a PE class or some sort of vigorous physical activity. When in actuality it really includes everything from range of motion and positioning to changing the position of the bed, performing bed mobility, any out of bed activity, and of course, ambulation. That's our main goal to maintain our independence. So many functional outcomes have been tied to a lack of mobility and increased mortality. So, you know, we really need to promote our abilities to maintain our functional independence. And so I know I've been a nurse for 30 years. This wasn't something that we really talked about 25, 30 years ago. Can you talk a little bit about, you know, what happened in the past with mobility management that led us to being, to understanding why this is such a problem? Oh, definitely. You know, I think still it's one of those topics that maybe isn't emphasized enough. We all have an understanding that it's so important. But, you know, really inactivity directly contributes to frailty, a loss of functional independence, and falling, which, you know, are all things that we really want to prevent in our patients. We really need those mobility programs. They've been found to decrease length of stay, 30-day hospital readmissions, the overall cost of patient care, and ultimately the need for institutionalization for patients. So, you know, typically in hospitals we have a fragmented approach and patients are discouraged from getting out of bed because there's a culture of risk avoidance. Obviously, we want to maintain patient safety as much as possible if that's natural and that's understandable. But I think we go to the extreme in trying to prevent our patients from being able to move themselves. And in the meantime, they become so deconditioned that they can't manage themselves at the end of their hospitalization. And I think, you know, today, this is much more of a topic of conversation than it was in the past. And I feel like, you know, those of us, the clinicians that are at the bedside have learned from our physical therapists that we need to get our patients moving. But what are you seeing in hospitals now? What kind of barriers are you seeing today in acute care setting? Well, you know, some of the same barriers we've always seen in the past. There is a culture of fragmentation, you know, everybody's got a job to do. And, you know, we'll allow the therapists to perform the mobility. And unfortunately, not every patient gets physical therapy. You know, we have a short time period in an entire 24 hour period that is spent with the patient. Occasionally, we'll have somebody who's really extremely proactive and helping that patient to perform movement. But, you know, it's really inconsistent. There might be one shift where somebody is extremely proactive and another shift or three following that, whereas, you know, the patient is absolutely allowed to just remain in bed. And in that day or day and a half, they lose all of the gains that they had made from the previous opportunity to be moving. So, you know, it's there's still not much consistency in how patients are allowed to perform their mobility. We try to maximize, you know, what a person is able to do within their time with us. And I think, you know, it's something that we really need to get everybody on board with. Any idea what system or process issues may be leading to these different individual behaviors? Well, there's quite a few, actually. You know, firstly, you know, there is such fragmentation in job duties. And, you know, everybody, you know, there really are time and staffing constraints. There's there's fear of being injured in mobilizing a patient. There are pieces of mobility equipment that are on the patient care units or at least available. And I think people feel insecure using the equipment, they maybe aren't confident in, you know, managing how to move the patient. There really doesn't feel like there's as much training or guidance, maybe mentoring as a person would would like to have, you know, it's it's always a delightful experience to have a staff member stay in the room during physical therapy and learn how to use the equipment or, you know, learn all the magic that we do with the patient to help them to perform at their best potential. You know, there are a lot of times the order sets themselves don't include any comment on mobility. There is no order that says, you know, patient must be out of bed. And a lot of times the even if there is an activity order, it's somewhat neglected because it isn't a medication. It isn't documented on a schedule routine like a medication would be. And I think our EMRs really are greatly at fault because it's so difficult to actually capture a patient's true abilities with the EMR documentation that we have available to us. So there there are quite a few little hurdles, I think that prevent the full potential for our patients. And it's not that people don't want the best for the patients. I just think it just gets kind of as an oversight in their day. Yes, I can I have seen that myself. And I'm sure that everybody that's watching this video has seen this. And so I'm curious though, how how do you think we can address the mixed messages that we're sending to patients, you know, you have the physical therapist that comes in and says it's really important you for you have to get out of bed three times a day at least sit in the chair, you need to move and then the nurse comes in and puts the side rails up and says stay in the bed because you might fall if you get out of the bed. So how do we address those mixed messages that we're sending to patients? Oh, definitely, definitely. I've observed that myself so many times. You know, it does those different messages come not just from between nurse and rehab as well. The families maybe have their own perceptions about what is an appropriate way to treat somebody who's gone through an illness or is going through an illness. Physicians may say one thing without even communicating with the rest of the staff. So all the communication that goes on in the room doesn't really seem to carry outside the room. So they do definitely get mixed messages. Having a multidisciplinary team that meets together, they have a system where they align their goals, they set goals for the day, they communicate how they're going to approach those goals. Having communication boards in the room where those goals are listed for the patient. It's really helpful if a physician goes in the room and says I want you to walk six times a day and actually writes it on that communication board. Good chance that somebody is going to follow through on that if that's been written down. So really, I think there needs to be better communication among the disciplines and also directly in front of the family. So they understand and the patient so that they understand that this message is consistently being carried through the team. We can educate as well. As patients come into the hospital, it really needs to be part of the basic education. The bed will make you sick. You need to be out of bed. You need to start moving. I use the phrase your bed is not your friend. That's where you sleep and that's all. People don't like to hear that so much sometimes, but mobility really is a medicine and it needs to be treated that way. And I think patients and families need to get that message as well. I love the way you said that. That the bed will make you sick. The bed is not your friend. That's great. So when a patient is in the hospital and they have physical therapy inpatient, how do we make sure that we set up their post discharge recovery appropriately so that they have realistic mobility goals, especially if they don't have anybody at any kind of home health or any other services at home? Oh, that's a great question. Yes, there is a gap in that follow up upon leaving the hospital. I think it really does start in the hospital, though, getting that consistent message that this mobility is important for you and teaching them their greatest level of mobility so that they understand what they're capable of. It is particularly difficult for patients who did not get any physical therapy in the hospital and particularly if they don't get any home health. I, my observations on home health, I have done some home health myself. It's real inconsistent what the practitioners are sharing as a message once the patient has gotten home as well. We all know that once a person gets in their own environment, they kind of take a different role in their management of themselves. But we really do need to teach them self-management strategies. I think we need to give them daily mobility goals, not only while they're in the hospital, but to teach that those daily mobility goals need to carry on outside of the hospital as well. Reinforce that education on how important it is and what part the mobility takes in their recovery to help them to maybe minimize the impact of the time that they're going to be spend recovering. Discharge instructions. I'm finding that the instructions are vague. They'll say something along the lines of daily activity recommendations are 150 minutes of activity a week. That seems a little intimidating if you've just left the hospital. It really needs to be more specific. They, you know, you really need to personalize it to a person's abilities. That's obviously something that we do in physical therapy. I will say, however, upon discharge, the patient's done with physical therapy and they don't feel like they need to continue with that. That really needs to be specific in the discharge recommendations. Great. So for our hospital administrators and other clinicians at the bedside who are trying to create improvement in this space, is there any recommendations that you have? If you could just tell one or two things to a hospital administrator to improve the mobility of their patients, what would it be? Oh boy. I'll try to keep it as short as possible. You know, I really think mobility needs to be seen as a standard of care. I think that everything should start from there. We need to see mobility as an intervention. Treat it as effective as a medication. I really think in order sets there needs to be an automatic order. So many order sets actually have an automatic order for bed rest rather than mobility recommendations. Established protocols have been proven to be extremely helpful. That's how you get those improved outcomes of the shorter length of stay, the reduced costs of care, the improved outcomes upon discharge, and the reduced hospital readmissions. So those are the, I think, the essential things we need to really start getting ingrained in our culture. Well, thank you, Debbie, so much for being here with us today. We really appreciate your time and your expertise on this and I hope that over the next several years we will be able to get everybody to understand that mobility is just as important as medication. I like how you said that as well. That's great. Thank you very much. It's been a real pleasure to talk with you. Great. All right, we'll have a wonderful day.