Improved outcomes by eliminating the negative effects of bed rest
Due to tighter reimbursement regulations from insurances, a new growing trend in hospitals across the country is to decrease the length of stay of patients. For a hospital to remain solvent and functional it has to manage its resources, staff, and bed availability by progressing those patients who are medically stable out to the next level of care faster. Remember medically stable and physically able are not always one in the same.
Evidence shows that patients who are up out of bed earlier have a better prognosis and a decreased length of stay. This is largely due to the avoidance of the negative physical effects bed rest can have on the body. It is true that sleep plays a major role in the bodies ability to heal. As we know during sleep, cells take the opportunity to grow and repair, however lying in bed all day can yield other unwanted physical outcomes. Most healthcare professionals are familiar with the common negative side effect of bed rest which are pressure ulcers or bed sores.
This hospital acquired infections/injury (HAI) tend to increase the duration of a patients hospital stay and are not eligible to receive reimbursement from insurances. For this reason, most hospitals are very diligent about preventive measures, such as rolling schedules, heel off boots, and hourly rounding.
Other negative effects of bed rest
But what about all the other negative effects of bed rest that do not get as much attention, but can equally effect patient outcomes in the long run. Musculoskeletal complications such as disuse atrophy of the muscles, muscle contractures, and disuse osteoporosis causing the bones to lose density occur within the first few days of bed rest. Respiratory complications such as alveolar collapse (atelectasis) occurs due to the constant pressure from the weight of an individuals chest restricting the movement and opening the lungs which usually occurs during inhalation.
These collapsed air sacs tend to pocket bacteria and create an opportunity for infection or pneumonia with patients; and often the elderly are more at risk. Other more serious cardiac complications include resting tachycardia, orthostatic positional changes in blood pressure, and venous stasis which could lead to blood clotting (DVTs) leading to pulmonary embolisms. Bed rest has several psychological effects on the patient including changes in their circadian rhythm causing difficulty sleeping, learned helplessness from not actively participating in their care, and disorientation which can lead to confusion and combative behavior.
Frequent transfer can be a game changer and money saver
Something as simple as transferring a patient out of bed frequently throughout the day can have a drastic effect on their outcomes and overall health and well-being by preventing these negative physical effects. By implementing an overall cultural change among our interdisciplinary teams can make a difference. Encouraging out of bed activity opposed to long duration of rest we can significantly improve patients physical and medical stability. This seemingly simple change often plays a role in patients discharge disposition increasing the probability for a home discharge versus costly rehabilitation. A patient who is able to safely function at home and receive further healthcare services via outpatient or home health saves healthcare dollars, which helps the healthcare system as a whole, bottom line.
What nurses can do
Nurses are the most important resource for encouraging the out of bed culture. Nurse’s discipline interacts with patients throughout the day. Nurses are the liaison between the patient and other disciplines. The physician, the PTs, the OTs, respiratory, etc. are only able to see patients for brief periods during the day, whereas nurses are there 24 hours. By reminding patients to get out of bed frequently throughout the day during hourly rounding, for vitals, or passing meds, patients will learn right away that mobility is highly encouraged.
Being up and out of bed more frequently throughout the day would require assisting patients with transferring, which is viewed as a job for therapists. However, transferring is the shared responsibility of all healthcare providers on staff. Yes functional mobility is the main scope of practice for physical therapy but this is not to be confused with having the sole responsibility for it. Therapy provides skilled intervention to improve the way in which patients move to decrease their burden of care for care givers and to improve their independence.
By rule, physical therapy should only be consulted if there is an acute change in a patient’s performance of a mobility task outside their previous level of function. By encouraging and assisting a patient out of bed early in their admission, nursing could actually evaluate the necessity of physical therapy intervention and thus more effectively determine the need for a consult.
How do you safely transfer a patient for the first time? key points
I’ve spoken with many nurses about patient transfers. I have concluded that there is a lack of formal training on patients transfer safety. If a patient hasn’t been evaluated by a therapist and you are unsure of how they should transfer; take the extra time to perform a few quick checks.
Assessing safety concerns such as vital signs, placement of lines and tubes, and utilization of all necessary equipment will increase the success of a first time transfer. Assessing gross strength, sensation, and command following in the bed prior to attempting transfer ensures the patient is ready to perform the task. When performing a standing transfer using an assistive device such as a rolling walker is preferred versus reaching for hand rails.
Always allow the patient extra time to initiate the transfer before pulling them to standing or forcing them to transfer. This extra second allows for improved orientation, balance, and decreases fear of falling. Allow the patient to assist with the transfer. Empower them to problem solve and actively engage them physically and cognitively. Often patients who stand up for the first time may have orthostatic hypotension (decreased blood pressure) symptoms of light headedness or just generalized weakness that may cause them to be off balance, dizzy, or feel weak.
Be sure they are able to safely maintain their balance independently. Then try to take a step away from the bed. If you remain close to the bed initially, they can sit right back down if they need. Once everyone is comfortable and feels safe, encourage the patient to walk toward the target and complete the transfer. This formula is obviously not universal and would require adjustment pending diagnosis or reason for a patients hospital admission, however it is a good framework to initiate a general patient to an out of bed transfer.
Results based research on patient outcomes is currently being done for the new move away from bed centric rooms in hospitals. The conversation has become that hospital rooms are set up to cater to the health care provider not necessarily the patients.
Bed centricity is the idea that hospital bed is where the patient stays in the center of the room and everything else surrounds it making it easier for staff to access. And to also leave the patient unattended for awhile and to let them know everything is within reach.
The argument is being made that if we center a patients care to suit their ability to get up and move around more frequently; they will do so. This type of behavior would then be similar to their familiar home environment where the bed is only used at night for sleep thus drastically encouraging an out of bed culture in our hospital systems and a decrease in the risk for the negative effects of bed rest.
About the author
After receiving a doctorate degree at Emory University in Physical Therapy, Kwaku has gone on to practice as a therapist in the acute care and inpatient rehabilitation settings. Concentrating mainly in patients with varying neuro diagnoses Kwaku has become well versed in neurorehabilitation and skilled mobility interventions for acute patient populations. At his time with Carolinas Rehabilitation he received several merit based awards for his efforts while working with patients including a KEIP award which recognizes key employees on staff. He was invited to be a guest lecturer for his colleagues at Pincrest Rehabilitation where he presented on motor recovery and the science behind neurorehabilitation. Additionally, he was the featured therapist in the short documentary Starting Over (https://vimeo.com/97367841), which depicted the recovery process of a young patient who suffered a spinal cord injury following a motor vehicle accident. Kwaku sites that success stories such as this are his biggest driving factor to continue his practice as a therapist as well as the positive feedback from patients, families, and co-workers. Kwaku is LSVT BIG Certified and plans to pursue neurological clinical specialization certification. He currently works as a traveling therapist and continues to add to his skill set through new experiences learned while performing contract work at several clinics across the country.