rehabinkmag Commentary, Issue 12

Ambulating Patients While Preventing the Spread of Infections in Acute Care: A Patient Care Conflict Resolution

Illustration by Livia Nguyen & Neramy Ganesan for rehabINK

Commentary

By Gurech James Wai

Background

The COVID-19 pandemic has elevated the tension between patient mobilization plans and infectious disease prevention protocols in Canadian healthcare facilities and beyond (1-4). An unintended impact of this conflict is the interruption of patient ambulation initiatives. A lack of movement during hospitalization is detrimental to the health and well-being of patients (5). It is a risk factor for hospital-associated functional decline, especially for older adults (5, 6). In essence, instituting protective public health measures and mobilizing patients to prevent disability and other harms to patients should not be exclusive practices. However, this is still happening, albeit unintended (7, 8).

End PJ Paralysis, an inpatient mobilization initiative, is one of the programs impacted by COVID-19-related restrictions on mobility within the hospital environments. End PJ Paralysis is a global movement started by Professor Brian Dolan in 2018 and implemented in clinical settings by the National Health Services (NHS) in the United Kingdom (UK)  (9, 10). The movement or initiative as referred to hereafter aims to preserve the functional ability and dignity of hospitalized older adults by enabling them to get up, dress in their personal clothes, and move about as much as possible instead of staying in bed for most of their waking hours (9, 11). The initiative advocates for an end to the physiological deconditioning (paralysis) associated with prolonged bedrest, which often occurs while patients are in hospital pyjamas (PJ) ((9, 10), hence the name End PJ Paralysis.

Hospitalized patients spend most of their time in hospital pyjamas and in bed, even when that is not medically necessary (12, 13). The risk of physiological deconditioning associated with prolonged bedrest has been highlighted in research as early as 1947. “The Dangers of Going to Bed” (14), is one of the early scholarly works that challenged this deep-rooted healthcare culture and the risk it poses to older patients (15, 16). End PJ Paralysis, through education and advocacy, builds on the challenge to this old healthcare culture that enables sedentary behavior (9, 17). Recent studies on hospitalized older adult cohort indicated that the patients spent up to 97% of their hospital days immobile and more than 60% of the time in pyjamas even though bedrest is indicated by physician orders for only 5% of the cases (12, 18, 19). Researchers call this detrimental acute care sedentary behavior an under-recognized epidemic (11, 20, 21).

Article_2_Image_2 copy
Karolina Grabowska
 (Pexels)

Urgency and Consideration

The epidemic of acute care sedentary behavior poses a high risk of adverse health outcomes, including functional decline, hospital-acquired-disability (HAD), institutionalization, rapid muscle mass loss, and aging, aerobic capacity decay, psychosocial problems, and pressure ulcers (17, 18, 22). HAD refers to a new or additional disability in activities of daily living (ADL), such as walking and using the toilet, at hospital discharge compared to the pre-admission baseline (23, 24). Alarmingly, research on the functional impact of 10 days of prolonged bedrest in older adults indicated that hospitalization is associated with a 65% increase in HAD, five times more likely to be institutionalized, and ten years equivalent increase muscle aging (6, 25, 26). Without timely intervention, these factors also amplify vulnerability to adverse health outcomes, including death (18, 22, 27). It is therefore evident that the implementation of infectious disease protocols that restrict patient mobilization for an extended period can have detrimental unintended health consequences for older adults.

The proposed course of action for resolving the patient care dilemma

The underpinning premise of this article is the need to continuously adapt and harmonize essential public health and rehabilitation practices. In light of the COVID-19 pandemic, a growing number of providers and researchers are calling for infection prevention and control, rehabilitation, and physical activity research agendas to reconcile related practices and policies across health systems (28-30). This would help bridgegaps in public health measures; gaps such as lack of adequate consideration of age diversity and vulnerability to disability associated with immobility during lockdowns. Relative to younger patient demographic, older adults are at a higher risk of disability and isolation because of the recent COVID-19 related public health restrictions within health facilities (31, 32). The lack of specific guidance and alternatives on how to continue to harness the benefits of patient ambulation and patient-centred initiatives is leading to patient care dilemmas in healthcare settings (34-36).

Pragmatic and adaptive leadership can help address this dilemma (37, 38). A possible course of action is for health leaders and policymakers to consider three important leadership and policy actions: develop and append safe patient mobilization practices to the Infection Prevention and Control (IPAC) standards, expand rehabilitation therapy capacity in the hospitals to help patient-care teams adapt and implement modified mobilization plans, and adopt emerging gerontechnology options. Gerontechnology is an emerging interdisciplinary field that blends gerontology and technology and focuses on designing environments for the well-being and independent living, and social participation of older persons (1, 31). This three-pronged action strategy could help resolve the dilemma, as elaborated below.

End PJ Paralysis advocates for an end to the physiological deconditionning (paralysis) associated with prolonged bedrest, which often occurs while patients are in hospital pyjamas (PJ) 

First, it is fundamental to develop safe mobilization protocols for inpatients as an annex to the IPAC Best Practices to harmonize emerging rehabilitation initiatives with public health protocols (35, 36). The World Health Organization (WHO) and Canadian public health authorities use annexes and reference documents extensively to address emerging issues and situations. The main documents, such as IPAC Best Practices and associated protocols, do not provide sufficient directions (35, 37). For instance, guidelines on the prevention of emerging respiratory infections in acute care (39) continuously annex emerging evidence to the main document to integrate new directions and create practice alignments. For instance, how to safely care for COVID-19 positive patients in an acute care setting while maintaining essential patient care. The same strategy could be used to address this patient mobilization dilemma.

This annex, as an extension of the main document (39), should achieve three objectives: create an alignment between necessary patient mobilization and facility infection prevention and control protocols. Such an alignment would mitigate any contradictions, bridge gaps in existing guidelines such as lack of consideration of diversity within inpatient population and communicate clear and consistent directions for implementation in all care settings.

The annex could provide comprehensive guidance on how to mobilize patients when a unit or facility-wide restriction is declared. It should indicate the acceptable alternatives and adaptations as well as applicable additional precautions (35, 36). Moreover, it should also explicitly address how to mobilize infectious and noninfectious inpatients during routine and non-routine practices (35) while protecting everyone from harm.

Moreover, the annex could be used to add an equity lens to IPAC Best Practices as they apply to patient mobility. The WHO, Health Canada, and other levels of public health regularly append additional information to their primary policy documents to remain current (37, 40). A recent example in light of COVID-19 is an annex with recommendations on how to meet the unique needs of patients with a disability. Especially those with significant limitations to using personal protective equipment, keeping distance, or accessing written public information (37, 41). However, there is little direction on mobility consideration for patients at a high risk of deconditioning and other harms, such as pressure ulcers, associated with prolonged bedrest. Therefore, it is imperative to consider an inclusive strategy to extend the benefits of both infection prevention and patient mobilization plans to all patients, including those with unique needs and physiological deconditioning vulnerability.

Second, there is a need to expand rehabilitation therapy capacity in hospitals to help implement simple exercises (23, 31). According to the WHO, rehabilitation needs for patients continue to be unmet due to inadequate staffing levels, low prioritization, and lack of resources such as equipment and consumables (42). This problem of unmet needs and low prioritization is being exacerbated by COVID-19 (4, 31, 42). To mitigate this impact, more rehabilitation therapists are needed to work with the rest of the hospital teams to adapt and implement simple exercises as routine interventions for preventing a physical decline in hospitalized seniors(43, 44). The therapists could also collaborate more on educating, supervising, and assisting inpatients to mobilize often, at least in their immediate care environments.

Rehabilitation therapists need the collaboration of other healthcare providers to help implement the modified mobility plans with a focus on improving intrinsic capacity – both physical and mental functional ability – using simple exercises (43, 44). They can routinely assist patients to sit, stand up, stretch, and do range of motion (ROM) activities. These are alternatives being trialed during the COVID-19 pandemic, where there are restrictions on distance walking and social interaction (8, 45, 46).

Finally, it is vital to explore and adapt promising interactive rehabilitation technologies to mobilize patients and maintain social interactions using Gerontechnologies (47, 48). Virtual reality exergames and instructional videos such as Jintronix, MATCH, and PATH are some of the promising innovations widely used to promote physical activity for older adults (23, 49-51). They have been proven to be effective and feasible alternatives to distance walking. Most of these supervised or unsupervised technology-mediated activities can be offered within limited care spaces while limiting the risk of infections (52).

These interactive rehabilitation platforms are widely available in stores and affordable to most people (47). They are portable and can be played at the bedside and followed by patients with or without supervision (23, 31, 49). Alas, they are rarely leveraged within the mainstream healthcare system. To strengthen uptake, health and policy leaders should consider enabling healthcare providers to prescribe approved and suitable technology alternatives to engage and mobilize older adults in acute care. Standard and pragmatic decision-making tools, such as decisional trees can help providers chose the most appropriate technology options for each patient (52). A decision tree here refers to a systematic approach for prescribing an individualized physical activity plan for older adults (52, 53). The assessment can determine the appropriateness, feasibility, and the needed adaption of various technologies for individual patients.

However, it is worth noting that there could be system and individual level barriers to the wide adoption of gerontechnology. First, although promising, the evidence on the effectiveness of the new technologies and the decision-making tools is still emerging (47, 48). Second, although most patients can afford it, the associated costs may be barriers to a small subset of patients, and this could be a potential access barrier to for those individuals. Therefore, the prospects of health professionals being enabled in time to prescribe these emerging exercise alternatives during this pandemic are improbable.

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Beytlik (Pexels)

Conclusion

Most of the patient ambulation initiatives such as End PJ Paralysis have been paused due to necessary public health restrictions aimed at preventing the spread of COVID-19 infections in hospital environments. Allied health professionals are concerned that older adults are bearing an added burden of isolation and physical decline as a result, albeit unintended. The article appeals to health and policy leaders to innovate and adapt by considering the following proposed action strategies to mitigate the unintended impact of public health restrictions on older adults: develop an annex to Infection Prevention and Control (IPAC) Best Practices to provide clear guidance on how to safely mobilize hospitalized older adults, who are vulnerable to functional decline, while preventing infections; increase rehabilitation capacity within hospital to help adapt rehabilitation practices; and leverage rehabilitation technology to maintain the functional ability of hospitalized patients during public health restrictions. There is no question that the restrictions are warranted; however, the unintended impact on the overall health of vulnerable older adults should not be overlooked, and the two practices need not preclude each other.

Acknowledgements

Featured illustration by Livia Nguyen and Neramy Ganesan for rehabINK.

To refer to this article, it can be cited as:

Gurech James Wai. Ambulating patients while preventing the spread of infections in acute care: a patient care conflict resolution
. rehabINK. 2022: Issue#12. Available from: https://rehabinkmag.com

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