Richard M. Allman, MD

The adverse outcomes associated with hospitalization of older patients, such as functional decline and increased nursing home placement, have been well documented.19 Low mobility, defined as being limited to a bed or chair, has also been associated with these adverse outcomes, even after controlling for severity of illness.10 Early ambulation has been a common practice for years following many types of orthopedic operations, including hip fracture repair and total joint replacement.11, 12 A recent study demonstrated that time to ambulation after surgery was an independent predictor of the development of postoperative complications such as pneumonia and delirium.13

In the early 1980s, early ambulation became the cornerstone of cardiac rehabilitation after acute myocardial infarction.14, 15 Until recently, with the exception of postmyocardial infarction, the use of early ambulation for patients admitted with medical illnesses has not been studied. In the last few years, researchers have begun to explore the use of early ambulation for patients after cardiac catheterization and for those admitted with deep‐vein thrombosis and pneumonia.1620 Although many of these studies have been small, they have found early ambulation not to be associated with worse outcomes. Indeed, a study of early ambulation for patients with community‐acquired pneumonia demonstrated decreased hospital costs and increased functional ability prior to discharge.20

Although the literature documents the adverse consequences associated with bed rest2123 and the beneficial effects of early ambulation, patients continue to spend a significant amount of their hospital stay limited to a bed or a chair. The prevalence of low mobility in older patients ranges from 23% to 33% during hospitalization for medical illness.9, 10 Despite the high prevalence and the associated adverse outcomes of low mobility among hospitalized older adults, the factors associated with low mobility in the hospital setting have not been systematically explored. Identification of such factors is the first step toward recognizing potentially modifiable factors and developing targeted interventions to improve hospital care.

We conceptualized a variety of factors or barriers that could potentially affect the level of mobility achieved by older hospitalized patients. Using professional experience and expert opinion, a conceptual model of potential barriers to mobility was developed (Fig. 1). As Figure 1 illustrates, the model has 4 major categories: patient‐related factors, including illness severity or comorbid conditions; treatment‐related factors such as catheters and intravenous lines; institution‐related factors such as nursing‐to‐patient ratio; and attitudinal factors related to perspectives on mobility and concerns about falling. This model was reviewed and feedback provided by a multidisciplinary group of colleagues including physicians, nurses, physical therapists, medical educators, and medical sociologists.

Figure 1

The objectives of this study were to employ qualitative methodology to identify and contextualize perceived barriers to mobility during hospitalization from the perspectives of older patients, their primary nurses, and their resident physicians; to compare and contrast the perceived barriers among these 3 groups; and to compare perceived barriers to mobility with our conceptual model.

METHODS

RESULTS

Fifty‐seven patients age 75 years were admitted to the medical service during the study period. Of those, 18 were excluded because they were too ill according to their physician (n = 6), had a nonmedical illness (n = 5), were discharged before being interviewed (n = 3), or were being cared for by a previously enrolled nurse or physician (n = 4). Of the 39 who were eligible for the study, 7 declined participation (6 patients, 1 physician), and data were lost for 3 as a result of technical difficulties with the tape recorder. A total of 29 participants had an interview transcribed: 10 patients, 10 nurses, and 9 physicians. As in other qualitative inquiries, data saturation was achieved after about 10 interviews,27 but we continued recruitment to permit comparison of themes identified by patients, nurses, and physicians.

Table 1 presents baseline characteristics of the patients. The mean age of the nurses was 34.9 9.9 years, all were female, and 60% were black. The mean age of the resident physicians was 29.1 2.2 years; 44% were female; and 78% were white, 22% were Latino, and none were black.

Figure 2 presents barriers most frequently noted by participants. These barriers were similar among the 3 groups for symptoms and hospital‐related factors like catheters and lack of staff. Lack of patient motivation, lack of ambulatory devices, and medical reasons necessitating bed rest were reported more frequently by health care providers than by patients. On admission, 40% of patients had bed rest ordered. By hospital day 3, all patients had out‐of‐bed orders, and 70% had had physical therapy ordered.

Figure 2

DISCUSSION

Many of the barriers described in the original conceptual model (Fig. 1) were cited by participants from all 3 groups: patients, nurses and physicians. These included patient‐related factors like symptoms and need for assistance, concern about falls, and lack of staff to assist with ambulation. Although attitudes toward mobility were cited in the model and by participants, there was significant disagreement between the 3 groups about the cause of the attitudinal barrier. Health care providers cited lack of patient motivation, whereas patients perceived health care providers as not being interested in mobility or viewing it as important. Health care providers frequently employed stereotypes to describe the potential reasons for the perceived attitudes toward mobility, often linking lack of motivation or interest in getting out of bed to patients being old. Patients linked the lack of importance attached to mobility to the numerous duties of staff members and believed that assistance with mobility was less important than other duties. Physicians and nurses were both more likely than patients to mention factors like urinary catheters, intravenous lines, and other medical reasons that necessitated bed rest. Although more than half the nurses commented on the lack of ambulatory devices for ambulation, no physicians and only 1 patient perceived this lack to be a barrier.

The model presented appears to have face validity, with participants citing many of the factors originally identified as barriers to mobility. The original model did not include consideration of environmental factors such as the number of chairs in the room or the location of the television. Such environmental factors can be conceptualized as institution‐related factors.

In addition, the impact of physician activity orders for bed rest was not specifically discussed by participants, although 45% of participants did comment on the need for bed rest because of a medical condition. A review of the medical records for activity orders indicated 40% of the patients initially had orders for bed rest. Another recent study demonstrated 33% of older patients were on bed rest at some point during their hospital stay10 and should be retained in the model as a treatment‐related consideration.

Several barriers noted in the original model and by participants may not be modifiable, such as comorbid conditions and illness severity. But other perceived barriers may be, and recognition of these factors present potential targets for a future multicomponent intervention to enhance hospital mobility. This multicomponent approach has been highly successful for geriatric syndromes like falls28 and delirium.29

During hospitalization, a focus on early removal of catheters and intravenous lines may encourage mobility. In a recent study absence of a urinary catheter was a predictor of patients with activity limitations regaining ambulatory ability while hospitalized.30 Availability of ambulatory devices may allow nurses to ambulate patients without consulting physical therapy. Another potential solution would be a hospitalwide walking program. The feasibility of a walking program was demonstrated in a small pilot study at a community‐based hospital using specially trained transporters to walk ward patients during slow periods. These periods included nights and weekends, when patients were more likely to be available and when physical therapy was often not present. On average, participants spent 2.4 days in the program, with an average of 5.6 walks per patient. However, additional research is needed, as the study was too small to demonstrate the effects of the walking program on length of stay or functional decline.31

Other barriers, while potentially modifiable, may be more difficult to address and may involve changing the culture of the hospital. For instance, concern about falls was a common theme, echoed by all 3 groups. Physicians were the most likely to spontaneously mention falls as a concern. The nurses shared this concern, frequently citing the use of bed rails as a part of their fall protocol, despite available literature demonstrating that this approach was not efficacious.3234 Nurses also consistently reported asking patients to call for help to ambulate, yet both patients and nurses noted a lack of nursing time to assist with ambulation. The default solution providers reported using was utilizing physical therapists, who were available to walk with patients only once or twice a day. Research on the best methods to prevent falls during hospitalization is limited. Given the current medicolegal environment and the emphasis on fall prevention by the Joint Commission on Accreditation of Healthcare Organizations and other government entities, it is not surprising that bed rest and mobility limitation are being used as a method of minimizing falls. Until data about successful fall‐prevention strategies are available, minimization of mobility may remain the default solution.

Strengths of the present study include the use of qualitative methods to explore potential barriers to mobility, a method that allows participants to describe in their own words their attitudes, beliefs, and expectations about mobility during hospitalization. Face‐to‐face interviewing of the 3 major groups involved in the hospital experience (patients, nurses, and physicians) facilitated the collection of detailed contextualized information on factors expected to affect a patient's level of mobility during hospitalization. This enabled hypothesis generation and sensitization to issues that need further quantitative investigation with larger groups.

The study also had several limitations. First, only resident physicians were included, and their answers may not reflect the opinions of other, more experienced physicians. However, resident physicians were chosen for this study because they play important roles in delivering hands‐on care in teaching hospitals and would need to be involved in any future interventions designed to enhanced patient mobility. Second, a sample size of 29 participants, approximately 10 persons in each group, may not reflect the thinking of those throughout the hospital. However, sampling was continued until no new themes or barriers emerged, and major themes emerged consistently throughout the interviews with all 3 groups. Interviews were conducted at a large, urban university hospital, and so results may not be generalizable to smaller community hospitals. Last, although the 3 major groupspatients, nurses, and physicianswere included in the interviews, the opinions of other stakeholders who may have had perspectives on mobility such as family members were not solicited and may need to be incorporated into the model.

This study presents the perceived barriers to mobility from the perspectives of patients their nurses and physicians. The modifiable and nonmodifiable factors that might affect mobility during hospitalization that made up the original theoretical model were consistent with the barriers cited by the participants. Importantly, this research has led to the identification of other barriers such as environmental factors that may also influence the mobility of older patients. This research has provided insights into potentially modifiable factors of the well‐documented phenomenon of low mobility of hospitalized older persons10 and identified several targets for a multicomponent intervention to minimize low mobility. Possible interventions include a progressive walking program initiated early in the hospital stay, provision of assistive devices to patients who need them, and early removal of catheters and intravenous lines. Further research is needed to explore other factors associated with low mobility, such as specific medical conditions for which bed rest may be ordered, and to evaluate the impact that specific interventions may have on the mobility of older persons during hospitalization.

The adverse outcomes associated with hospitalization of older patients, such as functional decline and increased nursing home placement, have been well documented.19 Low mobility, defined as being limited to a bed or chair, has also been associated with these adverse outcomes, even after controlling for severity of illness.10 Early ambulation has been a common practice for years following many types of orthopedic operations, including hip fracture repair and total joint replacement.11, 12 A recent study demonstrated that time to ambulation after surgery was an independent predictor of the development of postoperative complications such as pneumonia and delirium.13

In the early 1980s, early ambulation became the cornerstone of cardiac rehabilitation after acute myocardial infarction.14, 15 Until recently, with the exception of postmyocardial infarction, the use of early ambulation for patients admitted with medical illnesses has not been studied. In the last few years, researchers have begun to explore the use of early ambulation for patients after cardiac catheterization and for those admitted with deep‐vein thrombosis and pneumonia.1620 Although many of these studies have been small, they have found early ambulation not to be associated with worse outcomes. Indeed, a study of early ambulation for patients with community‐acquired pneumonia demonstrated decreased hospital costs and increased functional ability prior to discharge.20

Although the literature documents the adverse consequences associated with bed rest2123 and the beneficial effects of early ambulation, patients continue to spend a significant amount of their hospital stay limited to a bed or a chair. The prevalence of low mobility in older patients ranges from 23% to 33% during hospitalization for medical illness.9, 10 Despite the high prevalence and the associated adverse outcomes of low mobility among hospitalized older adults, the factors associated with low mobility in the hospital setting have not been systematically explored. Identification of such factors is the first step toward recognizing potentially modifiable factors and developing targeted interventions to improve hospital care.

We conceptualized a variety of factors or barriers that could potentially affect the level of mobility achieved by older hospitalized patients. Using professional experience and expert opinion, a conceptual model of potential barriers to mobility was developed (Fig. 1). As Figure 1 illustrates, the model has 4 major categories: patient‐related factors, including illness severity or comorbid conditions; treatment‐related factors such as catheters and intravenous lines; institution‐related factors such as nursing‐to‐patient ratio; and attitudinal factors related to perspectives on mobility and concerns about falling. This model was reviewed and feedback provided by a multidisciplinary group of colleagues including physicians, nurses, physical therapists, medical educators, and medical sociologists.

Figure 1

The objectives of this study were to employ qualitative methodology to identify and contextualize perceived barriers to mobility during hospitalization from the perspectives of older patients, their primary nurses, and their resident physicians; to compare and contrast the perceived barriers among these 3 groups; and to compare perceived barriers to mobility with our conceptual model.

METHODS

RESULTS

Fifty‐seven patients age 75 years were admitted to the medical service during the study period. Of those, 18 were excluded because they were too ill according to their physician (n = 6), had a nonmedical illness (n = 5), were discharged before being interviewed (n = 3), or were being cared for by a previously enrolled nurse or physician (n = 4). Of the 39 who were eligible for the study, 7 declined participation (6 patients, 1 physician), and data were lost for 3 as a result of technical difficulties with the tape recorder. A total of 29 participants had an interview transcribed: 10 patients, 10 nurses, and 9 physicians. As in other qualitative inquiries, data saturation was achieved after about 10 interviews,27 but we continued recruitment to permit comparison of themes identified by patients, nurses, and physicians.

Table 1 presents baseline characteristics of the patients. The mean age of the nurses was 34.9 9.9 years, all were female, and 60% were black. The mean age of the resident physicians was 29.1 2.2 years; 44% were female; and 78% were white, 22% were Latino, and none were black.

Figure 2 presents barriers most frequently noted by participants. These barriers were similar among the 3 groups for symptoms and hospital‐related factors like catheters and lack of staff. Lack of patient motivation, lack of ambulatory devices, and medical reasons necessitating bed rest were reported more frequently by health care providers than by patients. On admission, 40% of patients had bed rest ordered. By hospital day 3, all patients had out‐of‐bed orders, and 70% had had physical therapy ordered.

Figure 2

DISCUSSION

Many of the barriers described in the original conceptual model (Fig. 1) were cited by participants from all 3 groups: patients, nurses and physicians. These included patient‐related factors like symptoms and need for assistance, concern about falls, and lack of staff to assist with ambulation. Although attitudes toward mobility were cited in the model and by participants, there was significant disagreement between the 3 groups about the cause of the attitudinal barrier. Health care providers cited lack of patient motivation, whereas patients perceived health care providers as not being interested in mobility or viewing it as important. Health care providers frequently employed stereotypes to describe the potential reasons for the perceived attitudes toward mobility, often linking lack of motivation or interest in getting out of bed to patients being old. Patients linked the lack of importance attached to mobility to the numerous duties of staff members and believed that assistance with mobility was less important than other duties. Physicians and nurses were both more likely than patients to mention factors like urinary catheters, intravenous lines, and other medical reasons that necessitated bed rest. Although more than half the nurses commented on the lack of ambulatory devices for ambulation, no physicians and only 1 patient perceived this lack to be a barrier.

The model presented appears to have face validity, with participants citing many of the factors originally identified as barriers to mobility. The original model did not include consideration of environmental factors such as the number of chairs in the room or the location of the television. Such environmental factors can be conceptualized as institution‐related factors.

In addition, the impact of physician activity orders for bed rest was not specifically discussed by participants, although 45% of participants did comment on the need for bed rest because of a medical condition. A review of the medical records for activity orders indicated 40% of the patients initially had orders for bed rest. Another recent study demonstrated 33% of older patients were on bed rest at some point during their hospital stay10 and should be retained in the model as a treatment‐related consideration.

Several barriers noted in the original model and by participants may not be modifiable, such as comorbid conditions and illness severity. But other perceived barriers may be, and recognition of these factors present potential targets for a future multicomponent intervention to enhance hospital mobility. This multicomponent approach has been highly successful for geriatric syndromes like falls28 and delirium.29

During hospitalization, a focus on early removal of catheters and intravenous lines may encourage mobility. In a recent study absence of a urinary catheter was a predictor of patients with activity limitations regaining ambulatory ability while hospitalized.30 Availability of ambulatory devices may allow nurses to ambulate patients without consulting physical therapy. Another potential solution would be a hospitalwide walking program. The feasibility of a walking program was demonstrated in a small pilot study at a community‐based hospital using specially trained transporters to walk ward patients during slow periods. These periods included nights and weekends, when patients were more likely to be available and when physical therapy was often not present. On average, participants spent 2.4 days in the program, with an average of 5.6 walks per patient. However, additional research is needed, as the study was too small to demonstrate the effects of the walking program on length of stay or functional decline.31

Other barriers, while potentially modifiable, may be more difficult to address and may involve changing the culture of the hospital. For instance, concern about falls was a common theme, echoed by all 3 groups. Physicians were the most likely to spontaneously mention falls as a concern. The nurses shared this concern, frequently citing the use of bed rails as a part of their fall protocol, despite available literature demonstrating that this approach was not efficacious.3234 Nurses also consistently reported asking patients to call for help to ambulate, yet both patients and nurses noted a lack of nursing time to assist with ambulation. The default solution providers reported using was utilizing physical therapists, who were available to walk with patients only once or twice a day. Research on the best methods to prevent falls during hospitalization is limited. Given the current medicolegal environment and the emphasis on fall prevention by the Joint Commission on Accreditation of Healthcare Organizations and other government entities, it is not surprising that bed rest and mobility limitation are being used as a method of minimizing falls. Until data about successful fall‐prevention strategies are available, minimization of mobility may remain the default solution.

Strengths of the present study include the use of qualitative methods to explore potential barriers to mobility, a method that allows participants to describe in their own words their attitudes, beliefs, and expectations about mobility during hospitalization. Face‐to‐face interviewing of the 3 major groups involved in the hospital experience (patients, nurses, and physicians) facilitated the collection of detailed contextualized information on factors expected to affect a patient's level of mobility during hospitalization. This enabled hypothesis generation and sensitization to issues that need further quantitative investigation with larger groups.

The study also had several limitations. First, only resident physicians were included, and their answers may not reflect the opinions of other, more experienced physicians. However, resident physicians were chosen for this study because they play important roles in delivering hands‐on care in teaching hospitals and would need to be involved in any future interventions designed to enhanced patient mobility. Second, a sample size of 29 participants, approximately 10 persons in each group, may not reflect the thinking of those throughout the hospital. However, sampling was continued until no new themes or barriers emerged, and major themes emerged consistently throughout the interviews with all 3 groups. Interviews were conducted at a large, urban university hospital, and so results may not be generalizable to smaller community hospitals. Last, although the 3 major groupspatients, nurses, and physicianswere included in the interviews, the opinions of other stakeholders who may have had perspectives on mobility such as family members were not solicited and may need to be incorporated into the model.

This study presents the perceived barriers to mobility from the perspectives of patients their nurses and physicians. The modifiable and nonmodifiable factors that might affect mobility during hospitalization that made up the original theoretical model were consistent with the barriers cited by the participants. Importantly, this research has led to the identification of other barriers such as environmental factors that may also influence the mobility of older patients. This research has provided insights into potentially modifiable factors of the well‐documented phenomenon of low mobility of hospitalized older persons10 and identified several targets for a multicomponent intervention to minimize low mobility. Possible interventions include a progressive walking program initiated early in the hospital stay, provision of assistive devices to patients who need them, and early removal of catheters and intravenous lines. Further research is needed to explore other factors associated with low mobility, such as specific medical conditions for which bed rest may be ordered, and to evaluate the impact that specific interventions may have on the mobility of older persons during hospitalization.

The adverse outcomes associated with hospitalization of older patients, such as functional decline and increased nursing home placement, have been well documented.19 Low mobility, defined as being limited to a bed or chair, has also been associated with these adverse outcomes, even after controlling for severity of illness.10 Early ambulation has been a common practice for years following many types of orthopedic operations, including hip fracture repair and total joint replacement.11, 12 A recent study demonstrated that time to ambulation after surgery was an independent predictor of the development of postoperative complications such as pneumonia and delirium.13

In the early 1980s, early ambulation became the cornerstone of cardiac rehabilitation after acute myocardial infarction.14, 15 Until recently, with the exception of postmyocardial infarction, the use of early ambulation for patients admitted with medical illnesses has not been studied. In the last few years, researchers have begun to explore the use of early ambulation for patients after cardiac catheterization and for those admitted with deep‐vein thrombosis and pneumonia.1620 Although many of these studies have been small, they have found early ambulation not to be associated with worse outcomes. Indeed, a study of early ambulation for patients with community‐acquired pneumonia demonstrated decreased hospital costs and increased functional ability prior to discharge.20

Although the literature documents the adverse consequences associated with bed rest2123 and the beneficial effects of early ambulation, patients continue to spend a significant amount of their hospital stay limited to a bed or a chair. The prevalence of low mobility in older patients ranges from 23% to 33% during hospitalization for medical illness.9, 10 Despite the high prevalence and the associated adverse outcomes of low mobility among hospitalized older adults, the factors associated with low mobility in the hospital setting have not been systematically explored. Identification of such factors is the first step toward recognizing potentially modifiable factors and developing targeted interventions to improve hospital care.

We conceptualized a variety of factors or barriers that could potentially affect the level of mobility achieved by older hospitalized patients. Using professional experience and expert opinion, a conceptual model of potential barriers to mobility was developed (Fig. 1). As Figure 1 illustrates, the model has 4 major categories: patient‐related factors, including illness severity or comorbid conditions; treatment‐related factors such as catheters and intravenous lines; institution‐related factors such as nursing‐to‐patient ratio; and attitudinal factors related to perspectives on mobility and concerns about falling. This model was reviewed and feedback provided by a multidisciplinary group of colleagues including physicians, nurses, physical therapists, medical educators, and medical sociologists.

Figure 1

The objectives of this study were to employ qualitative methodology to identify and contextualize perceived barriers to mobility during hospitalization from the perspectives of older patients, their primary nurses, and their resident physicians; to compare and contrast the perceived barriers among these 3 groups; and to compare perceived barriers to mobility with our conceptual model.

METHODS

RESULTS

Fifty‐seven patients age 75 years were admitted to the medical service during the study period. Of those, 18 were excluded because they were too ill according to their physician (n = 6), had a nonmedical illness (n = 5), were discharged before being interviewed (n = 3), or were being cared for by a previously enrolled nurse or physician (n = 4). Of the 39 who were eligible for the study, 7 declined participation (6 patients, 1 physician), and data were lost for 3 as a result of technical difficulties with the tape recorder. A total of 29 participants had an interview transcribed: 10 patients, 10 nurses, and 9 physicians. As in other qualitative inquiries, data saturation was achieved after about 10 interviews,27 but we continued recruitment to permit comparison of themes identified by patients, nurses, and physicians.

Table 1 presents baseline characteristics of the patients. The mean age of the nurses was 34.9 9.9 years, all were female, and 60% were black. The mean age of the resident physicians was 29.1 2.2 years; 44% were female; and 78% were white, 22% were Latino, and none were black.

Figure 2 presents barriers most frequently noted by participants. These barriers were similar among the 3 groups for symptoms and hospital‐related factors like catheters and lack of staff. Lack of patient motivation, lack of ambulatory devices, and medical reasons necessitating bed rest were reported more frequently by health care providers than by patients. On admission, 40% of patients had bed rest ordered. By hospital day 3, all patients had out‐of‐bed orders, and 70% had had physical therapy ordered.

Figure 2

DISCUSSION

Many of the barriers described in the original conceptual model (Fig. 1) were cited by participants from all 3 groups: patients, nurses and physicians. These included patient‐related factors like symptoms and need for assistance, concern about falls, and lack of staff to assist with ambulation. Although attitudes toward mobility were cited in the model and by participants, there was significant disagreement between the 3 groups about the cause of the attitudinal barrier. Health care providers cited lack of patient motivation, whereas patients perceived health care providers as not being interested in mobility or viewing it as important. Health care providers frequently employed stereotypes to describe the potential reasons for the perceived attitudes toward mobility, often linking lack of motivation or interest in getting out of bed to patients being old. Patients linked the lack of importance attached to mobility to the numerous duties of staff members and believed that assistance with mobility was less important than other duties. Physicians and nurses were both more likely than patients to mention factors like urinary catheters, intravenous lines, and other medical reasons that necessitated bed rest. Although more than half the nurses commented on the lack of ambulatory devices for ambulation, no physicians and only 1 patient perceived this lack to be a barrier.

The model presented appears to have face validity, with participants citing many of the factors originally identified as barriers to mobility. The original model did not include consideration of environmental factors such as the number of chairs in the room or the location of the television. Such environmental factors can be conceptualized as institution‐related factors.

In addition, the impact of physician activity orders for bed rest was not specifically discussed by participants, although 45% of participants did comment on the need for bed rest because of a medical condition. A review of the medical records for activity orders indicated 40% of the patients initially had orders for bed rest. Another recent study demonstrated 33% of older patients were on bed rest at some point during their hospital stay10 and should be retained in the model as a treatment‐related consideration.

Several barriers noted in the original model and by participants may not be modifiable, such as comorbid conditions and illness severity. But other perceived barriers may be, and recognition of these factors present potential targets for a future multicomponent intervention to enhance hospital mobility. This multicomponent approach has been highly successful for geriatric syndromes like falls28 and delirium.29

During hospitalization, a focus on early removal of catheters and intravenous lines may encourage mobility. In a recent study absence of a urinary catheter was a predictor of patients with activity limitations regaining ambulatory ability while hospitalized.30 Availability of ambulatory devices may allow nurses to ambulate patients without consulting physical therapy. Another potential solution would be a hospitalwide walking program. The feasibility of a walking program was demonstrated in a small pilot study at a community‐based hospital using specially trained transporters to walk ward patients during slow periods. These periods included nights and weekends, when patients were more likely to be available and when physical therapy was often not present. On average, participants spent 2.4 days in the program, with an average of 5.6 walks per patient. However, additional research is needed, as the study was too small to demonstrate the effects of the walking program on length of stay or functional decline.31

Other barriers, while potentially modifiable, may be more difficult to address and may involve changing the culture of the hospital. For instance, concern about falls was a common theme, echoed by all 3 groups. Physicians were the most likely to spontaneously mention falls as a concern. The nurses shared this concern, frequently citing the use of bed rails as a part of their fall protocol, despite available literature demonstrating that this approach was not efficacious.3234 Nurses also consistently reported asking patients to call for help to ambulate, yet both patients and nurses noted a lack of nursing time to assist with ambulation. The default solution providers reported using was utilizing physical therapists, who were available to walk with patients only once or twice a day. Research on the best methods to prevent falls during hospitalization is limited. Given the current medicolegal environment and the emphasis on fall prevention by the Joint Commission on Accreditation of Healthcare Organizations and other government entities, it is not surprising that bed rest and mobility limitation are being used as a method of minimizing falls. Until data about successful fall‐prevention strategies are available, minimization of mobility may remain the default solution.

Strengths of the present study include the use of qualitative methods to explore potential barriers to mobility, a method that allows participants to describe in their own words their attitudes, beliefs, and expectations about mobility during hospitalization. Face‐to‐face interviewing of the 3 major groups involved in the hospital experience (patients, nurses, and physicians) facilitated the collection of detailed contextualized information on factors expected to affect a patient's level of mobility during hospitalization. This enabled hypothesis generation and sensitization to issues that need further quantitative investigation with larger groups.

The study also had several limitations. First, only resident physicians were included, and their answers may not reflect the opinions of other, more experienced physicians. However, resident physicians were chosen for this study because they play important roles in delivering hands‐on care in teaching hospitals and would need to be involved in any future interventions designed to enhanced patient mobility. Second, a sample size of 29 participants, approximately 10 persons in each group, may not reflect the thinking of those throughout the hospital. However, sampling was continued until no new themes or barriers emerged, and major themes emerged consistently throughout the interviews with all 3 groups. Interviews were conducted at a large, urban university hospital, and so results may not be generalizable to smaller community hospitals. Last, although the 3 major groupspatients, nurses, and physicianswere included in the interviews, the opinions of other stakeholders who may have had perspectives on mobility such as family members were not solicited and may need to be incorporated into the model.

This study presents the perceived barriers to mobility from the perspectives of patients their nurses and physicians. The modifiable and nonmodifiable factors that might affect mobility during hospitalization that made up the original theoretical model were consistent with the barriers cited by the participants. Importantly, this research has led to the identification of other barriers such as environmental factors that may also influence the mobility of older patients. This research has provided insights into potentially modifiable factors of the well‐documented phenomenon of low mobility of hospitalized older persons10 and identified several targets for a multicomponent intervention to minimize low mobility. Possible interventions include a progressive walking program initiated early in the hospital stay, provision of assistive devices to patients who need them, and early removal of catheters and intravenous lines. Further research is needed to explore other factors associated with low mobility, such as specific medical conditions for which bed rest may be ordered, and to evaluate the impact that specific interventions may have on the mobility of older persons during hospitalization.

Functional decline, defined as loss of the ability to care for oneself, commonly occurs during hospitalization, being experienced by up to 65% of older adults.14 Frequently, recovery of functional ability does not occur by the time of discharge from the hospital, despite resolution of the medical condition responsible for admission to the hospital.1, 5 Causes of the declining ability to perform activities of daily living (ADLs) are multiple and include both acute illness and adverse events associated with hospitalization.4, 6, 7 The functional decline experienced by older persons during hospitalization is a strong predictor of length of stay, nursing home placement, and mortality.8 Loss of ambulatory ability specifically has been noted to occur in 17%‐65% of hospitalized older patients, usually within days of admission, with few recovering this ability prior to discharge.2, 4, 5, 9 Importantly, ambulatory ability is significantly associated with a decline in other ADLs.9

Although several studies have explored risk factors associated with general functional decline during hospitalization,4, 7, 10, 11 only one study specifically examined risk factors associated with loss of ambulatory ability. In a cohort of participants who were largely independently performing ADLs on admission to the hospital, Mahoney et al. found age 85 years, white race, use of a walker, and functional impairment prior to being hospitalized were significant predictors of newly having walking dependence.12

Ambulatory ability could also be affected by a variety of other factors not examined in the Mahoney et al. study; these include severity of illness, bed rest, and hospital‐related treatments such as restraints or urinary catheters. In addition, little is known about predictors of recovery of ambulatory ability in patients expected to have activity limitations on admission who are dependent in most or all ADLs. The deconditioning associated with bed rest and reduced mobility has been described as one of the most predictable causes of functional decline, including loss of ambulatory ability, observed in older hospitalized patients.13 In one study, patients whose activity was limited to a bed or chair during hospitalization were 5.6 times more likely to develop functional decline than those who walked at all, even after controlling for other covariates including severity of illness and comorbidity.14 Those patients with both activity limitations and dependence in most or all ADLs represent an important subset of all hospitalized older patients who might be expected to be at higher risk of developing new ambulatory dependence. The ability to identify, at admission, those patients who will recover ambulatory ability may have important implications for discharge planning as well as for the development of preventive strategies.

The objective of the present study was to define patient demographic, illness severity, comorbid illness, and hospital‐related variables that are independent and significant predictors of regaining ambulatory ability prior to hospital discharge in a cohort of patients who had significant activity limitations and functional impairment at the time of admission to the hospital.

METHODS

RESULTS

For this study, 286 participants met all eligibility criteria, with 119 (42%) regaining ambulatory ability during hospitalization. Mean age of study participants was 73 9 years, with 12% of participants more than 85 years old. On admission, 214 patients (75%) were dependent in all 7 ADLs. Mean length of stay ( SD) was 12.3 6.5 days, with a range of 1‐31 days. Table 1 presents the cohort characteristics and the unadjusted effects of each variable for predicting those who did and did not recover ambulatory ability by characteristic. The P value of a variable in Table 1 indicates how significant that variable was, as determined with a simple logistic regression analysis. The unadjusted odds ratio of each variable is presented in Table 2 in order to facilitate comparisons with the adjusted odds ratios from the multivariate models. Analysis of the effects of the unadjusted single variables showed that age was a significant predictor, with older patients less likely to regain ambulatory ability. Several global health measures and hospital‐related factors were also significantly different between those who recovered and those who did not recover ambulatory ability, as summarized in Table 1. Importantly, length of stay was not significantly associated with recovery.

Table 2 shows the effects of adjusting the model for important covariables in a sequential fashion. Model 1 shows that longer length of stay and older age are associated with reduced odds of regaining ambulatory ability after adjusting for other demographic variables. However, age and length of stay were no longer significant after adjusting for global health measures and specific medical problems (Model 2). As demonstrated by the full model (Model 4), the participants who regained ambulatory ability were more likely to be unmarried, have a longer physician‐rated life expectancy, not have a diagnosis of deep vein thrombosis, not have physical restraints or a urinary catheter in use, and have greater bed mobility at admission.

Predictors that remained significant in the final multivariate model (Model 4) were summed in order to determine the proportion of patients who had one predictor versus those who had more than one predictor. Figure 1 shows the percentage of those who recovered ambulatory ability according to number of predictors, ranging from one to all 6 predictors. The results demonstrate a graded relationship, with number of predictors positively correlated with percentage of those who recovered ambulatory ability (P < .0001).

Figure 1

Patients who died prior to discharge were more likely to be male and have altered mental status, a urinary catheter, restraints, a shorter physician‐rated life expectancy, lower admission bed mobility, and increased severity of illness compared to those who survived. When the 34 patients who died were excluded from the multivariate analysis, the factors predicting ambulatory recovery were unchanged from those reported in Model 4 of Table 2.

DISCUSSION

In this study of older hospitalized patients, approximately 40% were able to regain their ambulatory ability despite being limited to the bed or chair on admission, having significant severity of illness, high level of use of restraints, and functional dependence on admission. Predictors of regaining ambulatory ability were identifiable at hospital admission. These predictors also were correlated with recovery of ambulatory ability in a graded fashion, lending support for the direct relationship between these predictors and recovery.

Physician‐rated life expectancy, a simple assessment that combines a physician's medical knowledge and clinical acumen, was demonstrated in our study to be a better predictor of recovery of ambulatory ability than more elaborate measures like the APACHE II17 and Charlson Comorbidity Index.16 This assessment can easily be done at the bedside and may help to guide discharge planning for the hospitalist physician. Nurse‐rated bed mobility at time of admission, which may reflect aspects of illness severity and cognitive status, was also able to predict recovery.

Of the 6 factors found to be independent predictors of recovery of ambulatory ability, 4 were related to mobility: lack of a DVT diagnosis, absence of a urinary catheter, absence of restraints, and nurse‐rated bed mobility at admission. In the group of patients initially expected to be confined to a bed or chair, those with additional mobility‐reducing factors, such as catheters and restraints, were less likely to recover, even after controlling for illness severity and comorbidity.

Marital status was not found to predict recovery of ambulatory ability in the simple unadjusted bivariate analysis, but after adjusting for other demographic, global health, and disease‐related variables, those who were unmarried were more likely to recover ambulatory ability. These interesting covariate‐adjusted effects for marital status have not been previously reported in the literature. One large study of the impact of marital status on hospital outcomes demonstrated those who were unmarried were more likely to require discharge to a nursing home and had slightly higher hospital costs and longer length of stay.19 Our findings may be related to such patients lacking support other than from themselves, with the possibility of being discharged to a nursing home an incentive to get up and walk.

Although age, race, and previous ADL status were found to be significant predictors in a previous study,12 we did not find this in our sample. This may be because, unlike in other studies, most of our patients had significant functional impairment on admission. The importance of age in our cohort disappeared when illness severity and comorbidities were added to the model.

The strengths of this study include having comprehensive patient‐related data on demographic, illness severity, comorbidity, and hospital‐related factors available, which enabled detailed analyses of predictors for regaining ambulatory ability. In particular, the ability to examine such factors as bed rest and hospital‐related treatments like restraint and catheter use, enabled this study to add significantly to the available knowledge of predictors of ambulatory recovery. The use of nurse interviews to obtain patient‐related data has been demonstrated in previous studies to be a preferred method of collecting data when compared to patient self‐report.20, 21 Examination of these factors in a cohort of patients who would be expected to be at very high risk for remaining bed‐ or chair bound, given their admission activity limitations and functional dependence, is also noteworthy.

Several important limitations deserve comment. Since the data were collected, average length of hospital stay generally has decreased. However, the patient population we studied continue to experience longer hospital stays than functionally intact patients. One recent study demonstrated that the length of hospital stay of patients who were dependent in one or more ADLs on admission was 35% longer than that of those not ADL dependent at admission.22 Seventy‐five percent of those in the present study cohort were dependent in all 7 ADLs and had a mean length of stay of 12.3 days. Despite the longer mean length of stay, 70% of those in the study cohort were discharged within 2 weeks of admission. In the university hospital where this research was conducted, mean length of stay ( SD) in 2004 was 6 8.6 days, but 10% of patients 55 years of age and older remained in the hospital for more than 2 weeks.23 This suggests there continue to be long‐stay patients in the current hospital environment, to which these findings may apply.

Standards of practice, such as for use of restraints, have also changed. In 1992, between 7.4% and 17% of all hospitalized medical patients were restrained, according to a literature review.24 A 1998 survey of 3 hospitals found the prevalence of restraints still ranged from 3.9% to 8.2% and noted that among the most common reasons reported for using restraints were to prevent patient disruption of therapy, to confine confused patients, and to reduce the number of falls.25 Thus, our study cohort would be more likely to be restrained, even in the current hospital environment, given that 43% of the cohort had altered mental status and that most were at risk for falls because of their poor functional status.26

Nevertheless, even though the use of restraints has declined since the data were collected for this study, this should affect neither the internal validity of the results nor the ability to address the question of what factors predict recovery of ambulatory ability. Indeed, the inclusion of patients on whom restraints are frequently used emphasizes the need for continued diligence in creating a restraint‐free environment in our hospitals. Data about the use of physical therapy services were not available in the study. Therefore, it is unknown to what extent the use of these services encouraged ambulation.

In this observational study, we found 6 factors associated with regaining ambulatory ability among hospitalized patients who had significant activity limitations and functional dependence on admission. These findings suggest predictors easily assessed by the hospitalist physician can help to identify those patients most likely to recover ambulatory ability prior to discharge. It also demonstrates the importance of mobility in maintaining function, given that many of the predictors are factors that either impede mobility such as restraints and urinary catheters or measure mobility such as admission bed mobility. Last, recognizing physician‐rated life expectancy as a strong independent predictor of recovery of ambulatory ability should encourage hospitalist physicians to continue to use their greatest tool, their clinical judgment, to determine who will recover ambulatory ability.

As most of these predictors can be identified on admission or shortly thereafter, these factors may be useful in helping physicians and other health care providers to predict the potential patients have to recover ambulatory ability. This information may help physicians identify patients who might benefit from early mobility programs, placement on hospital units where mobility will be enhanced, or the early initiation of discharge planning for those patients identified as unlikely to regain ambulation ability. In addition, addressing factors that are potentially modifiable, such as low bed mobility and the use of urinary catheters and restraints may not only improve the chance of recovering ambulatory ability but would also improve the quality of care provided to older patients.

Functional decline, defined as loss of the ability to care for oneself, commonly occurs during hospitalization, being experienced by up to 65% of older adults.14 Frequently, recovery of functional ability does not occur by the time of discharge from the hospital, despite resolution of the medical condition responsible for admission to the hospital.1, 5 Causes of the declining ability to perform activities of daily living (ADLs) are multiple and include both acute illness and adverse events associated with hospitalization.4, 6, 7 The functional decline experienced by older persons during hospitalization is a strong predictor of length of stay, nursing home placement, and mortality.8 Loss of ambulatory ability specifically has been noted to occur in 17%‐65% of hospitalized older patients, usually within days of admission, with few recovering this ability prior to discharge.2, 4, 5, 9 Importantly, ambulatory ability is significantly associated with a decline in other ADLs.9

Although several studies have explored risk factors associated with general functional decline during hospitalization,4, 7, 10, 11 only one study specifically examined risk factors associated with loss of ambulatory ability. In a cohort of participants who were largely independently performing ADLs on admission to the hospital, Mahoney et al. found age 85 years, white race, use of a walker, and functional impairment prior to being hospitalized were significant predictors of newly having walking dependence.12

Ambulatory ability could also be affected by a variety of other factors not examined in the Mahoney et al. study; these include severity of illness, bed rest, and hospital‐related treatments such as restraints or urinary catheters. In addition, little is known about predictors of recovery of ambulatory ability in patients expected to have activity limitations on admission who are dependent in most or all ADLs. The deconditioning associated with bed rest and reduced mobility has been described as one of the most predictable causes of functional decline, including loss of ambulatory ability, observed in older hospitalized patients.13 In one study, patients whose activity was limited to a bed or chair during hospitalization were 5.6 times more likely to develop functional decline than those who walked at all, even after controlling for other covariates including severity of illness and comorbidity.14 Those patients with both activity limitations and dependence in most or all ADLs represent an important subset of all hospitalized older patients who might be expected to be at higher risk of developing new ambulatory dependence. The ability to identify, at admission, those patients who will recover ambulatory ability may have important implications for discharge planning as well as for the development of preventive strategies.

The objective of the present study was to define patient demographic, illness severity, comorbid illness, and hospital‐related variables that are independent and significant predictors of regaining ambulatory ability prior to hospital discharge in a cohort of patients who had significant activity limitations and functional impairment at the time of admission to the hospital.

METHODS

RESULTS

For this study, 286 participants met all eligibility criteria, with 119 (42%) regaining ambulatory ability during hospitalization. Mean age of study participants was 73 9 years, with 12% of participants more than 85 years old. On admission, 214 patients (75%) were dependent in all 7 ADLs. Mean length of stay ( SD) was 12.3 6.5 days, with a range of 1‐31 days. Table 1 presents the cohort characteristics and the unadjusted effects of each variable for predicting those who did and did not recover ambulatory ability by characteristic. The P value of a variable in Table 1 indicates how significant that variable was, as determined with a simple logistic regression analysis. The unadjusted odds ratio of each variable is presented in Table 2 in order to facilitate comparisons with the adjusted odds ratios from the multivariate models. Analysis of the effects of the unadjusted single variables showed that age was a significant predictor, with older patients less likely to regain ambulatory ability. Several global health measures and hospital‐related factors were also significantly different between those who recovered and those who did not recover ambulatory ability, as summarized in Table 1. Importantly, length of stay was not significantly associated with recovery.

Table 2 shows the effects of adjusting the model for important covariables in a sequential fashion. Model 1 shows that longer length of stay and older age are associated with reduced odds of regaining ambulatory ability after adjusting for other demographic variables. However, age and length of stay were no longer significant after adjusting for global health measures and specific medical problems (Model 2). As demonstrated by the full model (Model 4), the participants who regained ambulatory ability were more likely to be unmarried, have a longer physician‐rated life expectancy, not have a diagnosis of deep vein thrombosis, not have physical restraints or a urinary catheter in use, and have greater bed mobility at admission.

Predictors that remained significant in the final multivariate model (Model 4) were summed in order to determine the proportion of patients who had one predictor versus those who had more than one predictor. Figure 1 shows the percentage of those who recovered ambulatory ability according to number of predictors, ranging from one to all 6 predictors. The results demonstrate a graded relationship, with number of predictors positively correlated with percentage of those who recovered ambulatory ability (P < .0001).

Figure 1

Patients who died prior to discharge were more likely to be male and have altered mental status, a urinary catheter, restraints, a shorter physician‐rated life expectancy, lower admission bed mobility, and increased severity of illness compared to those who survived. When the 34 patients who died were excluded from the multivariate analysis, the factors predicting ambulatory recovery were unchanged from those reported in Model 4 of Table 2.

DISCUSSION

In this study of older hospitalized patients, approximately 40% were able to regain their ambulatory ability despite being limited to the bed or chair on admission, having significant severity of illness, high level of use of restraints, and functional dependence on admission. Predictors of regaining ambulatory ability were identifiable at hospital admission. These predictors also were correlated with recovery of ambulatory ability in a graded fashion, lending support for the direct relationship between these predictors and recovery.

Physician‐rated life expectancy, a simple assessment that combines a physician's medical knowledge and clinical acumen, was demonstrated in our study to be a better predictor of recovery of ambulatory ability than more elaborate measures like the APACHE II17 and Charlson Comorbidity Index.16 This assessment can easily be done at the bedside and may help to guide discharge planning for the hospitalist physician. Nurse‐rated bed mobility at time of admission, which may reflect aspects of illness severity and cognitive status, was also able to predict recovery.

Of the 6 factors found to be independent predictors of recovery of ambulatory ability, 4 were related to mobility: lack of a DVT diagnosis, absence of a urinary catheter, absence of restraints, and nurse‐rated bed mobility at admission. In the group of patients initially expected to be confined to a bed or chair, those with additional mobility‐reducing factors, such as catheters and restraints, were less likely to recover, even after controlling for illness severity and comorbidity.

Marital status was not found to predict recovery of ambulatory ability in the simple unadjusted bivariate analysis, but after adjusting for other demographic, global health, and disease‐related variables, those who were unmarried were more likely to recover ambulatory ability. These interesting covariate‐adjusted effects for marital status have not been previously reported in the literature. One large study of the impact of marital status on hospital outcomes demonstrated those who were unmarried were more likely to require discharge to a nursing home and had slightly higher hospital costs and longer length of stay.19 Our findings may be related to such patients lacking support other than from themselves, with the possibility of being discharged to a nursing home an incentive to get up and walk.

Although age, race, and previous ADL status were found to be significant predictors in a previous study,12 we did not find this in our sample. This may be because, unlike in other studies, most of our patients had significant functional impairment on admission. The importance of age in our cohort disappeared when illness severity and comorbidities were added to the model.

The strengths of this study include having comprehensive patient‐related data on demographic, illness severity, comorbidity, and hospital‐related factors available, which enabled detailed analyses of predictors for regaining ambulatory ability. In particular, the ability to examine such factors as bed rest and hospital‐related treatments like restraint and catheter use, enabled this study to add significantly to the available knowledge of predictors of ambulatory recovery. The use of nurse interviews to obtain patient‐related data has been demonstrated in previous studies to be a preferred method of collecting data when compared to patient self‐report.20, 21 Examination of these factors in a cohort of patients who would be expected to be at very high risk for remaining bed‐ or chair bound, given their admission activity limitations and functional dependence, is also noteworthy.

Several important limitations deserve comment. Since the data were collected, average length of hospital stay generally has decreased. However, the patient population we studied continue to experience longer hospital stays than functionally intact patients. One recent study demonstrated that the length of hospital stay of patients who were dependent in one or more ADLs on admission was 35% longer than that of those not ADL dependent at admission.22 Seventy‐five percent of those in the present study cohort were dependent in all 7 ADLs and had a mean length of stay of 12.3 days. Despite the longer mean length of stay, 70% of those in the study cohort were discharged within 2 weeks of admission. In the university hospital where this research was conducted, mean length of stay ( SD) in 2004 was 6 8.6 days, but 10% of patients 55 years of age and older remained in the hospital for more than 2 weeks.23 This suggests there continue to be long‐stay patients in the current hospital environment, to which these findings may apply.

Standards of practice, such as for use of restraints, have also changed. In 1992, between 7.4% and 17% of all hospitalized medical patients were restrained, according to a literature review.24 A 1998 survey of 3 hospitals found the prevalence of restraints still ranged from 3.9% to 8.2% and noted that among the most common reasons reported for using restraints were to prevent patient disruption of therapy, to confine confused patients, and to reduce the number of falls.25 Thus, our study cohort would be more likely to be restrained, even in the current hospital environment, given that 43% of the cohort had altered mental status and that most were at risk for falls because of their poor functional status.26

Nevertheless, even though the use of restraints has declined since the data were collected for this study, this should affect neither the internal validity of the results nor the ability to address the question of what factors predict recovery of ambulatory ability. Indeed, the inclusion of patients on whom restraints are frequently used emphasizes the need for continued diligence in creating a restraint‐free environment in our hospitals. Data about the use of physical therapy services were not available in the study. Therefore, it is unknown to what extent the use of these services encouraged ambulation.

In this observational study, we found 6 factors associated with regaining ambulatory ability among hospitalized patients who had significant activity limitations and functional dependence on admission. These findings suggest predictors easily assessed by the hospitalist physician can help to identify those patients most likely to recover ambulatory ability prior to discharge. It also demonstrates the importance of mobility in maintaining function, given that many of the predictors are factors that either impede mobility such as restraints and urinary catheters or measure mobility such as admission bed mobility. Last, recognizing physician‐rated life expectancy as a strong independent predictor of recovery of ambulatory ability should encourage hospitalist physicians to continue to use their greatest tool, their clinical judgment, to determine who will recover ambulatory ability.

As most of these predictors can be identified on admission or shortly thereafter, these factors may be useful in helping physicians and other health care providers to predict the potential patients have to recover ambulatory ability. This information may help physicians identify patients who might benefit from early mobility programs, placement on hospital units where mobility will be enhanced, or the early initiation of discharge planning for those patients identified as unlikely to regain ambulation ability. In addition, addressing factors that are potentially modifiable, such as low bed mobility and the use of urinary catheters and restraints may not only improve the chance of recovering ambulatory ability but would also improve the quality of care provided to older patients.

Functional decline, defined as loss of the ability to care for oneself, commonly occurs during hospitalization, being experienced by up to 65% of older adults.14 Frequently, recovery of functional ability does not occur by the time of discharge from the hospital, despite resolution of the medical condition responsible for admission to the hospital.1, 5 Causes of the declining ability to perform activities of daily living (ADLs) are multiple and include both acute illness and adverse events associated with hospitalization.4, 6, 7 The functional decline experienced by older persons during hospitalization is a strong predictor of length of stay, nursing home placement, and mortality.8 Loss of ambulatory ability specifically has been noted to occur in 17%‐65% of hospitalized older patients, usually within days of admission, with few recovering this ability prior to discharge.2, 4, 5, 9 Importantly, ambulatory ability is significantly associated with a decline in other ADLs.9

Although several studies have explored risk factors associated with general functional decline during hospitalization,4, 7, 10, 11 only one study specifically examined risk factors associated with loss of ambulatory ability. In a cohort of participants who were largely independently performing ADLs on admission to the hospital, Mahoney et al. found age 85 years, white race, use of a walker, and functional impairment prior to being hospitalized were significant predictors of newly having walking dependence.12

Ambulatory ability could also be affected by a variety of other factors not examined in the Mahoney et al. study; these include severity of illness, bed rest, and hospital‐related treatments such as restraints or urinary catheters. In addition, little is known about predictors of recovery of ambulatory ability in patients expected to have activity limitations on admission who are dependent in most or all ADLs. The deconditioning associated with bed rest and reduced mobility has been described as one of the most predictable causes of functional decline, including loss of ambulatory ability, observed in older hospitalized patients.13 In one study, patients whose activity was limited to a bed or chair during hospitalization were 5.6 times more likely to develop functional decline than those who walked at all, even after controlling for other covariates including severity of illness and comorbidity.14 Those patients with both activity limitations and dependence in most or all ADLs represent an important subset of all hospitalized older patients who might be expected to be at higher risk of developing new ambulatory dependence. The ability to identify, at admission, those patients who will recover ambulatory ability may have important implications for discharge planning as well as for the development of preventive strategies.

The objective of the present study was to define patient demographic, illness severity, comorbid illness, and hospital‐related variables that are independent and significant predictors of regaining ambulatory ability prior to hospital discharge in a cohort of patients who had significant activity limitations and functional impairment at the time of admission to the hospital.

METHODS

RESULTS

For this study, 286 participants met all eligibility criteria, with 119 (42%) regaining ambulatory ability during hospitalization. Mean age of study participants was 73 9 years, with 12% of participants more than 85 years old. On admission, 214 patients (75%) were dependent in all 7 ADLs. Mean length of stay ( SD) was 12.3 6.5 days, with a range of 1‐31 days. Table 1 presents the cohort characteristics and the unadjusted effects of each variable for predicting those who did and did not recover ambulatory ability by characteristic. The P value of a variable in Table 1 indicates how significant that variable was, as determined with a simple logistic regression analysis. The unadjusted odds ratio of each variable is presented in Table 2 in order to facilitate comparisons with the adjusted odds ratios from the multivariate models. Analysis of the effects of the unadjusted single variables showed that age was a significant predictor, with older patients less likely to regain ambulatory ability. Several global health measures and hospital‐related factors were also significantly different between those who recovered and those who did not recover ambulatory ability, as summarized in Table 1. Importantly, length of stay was not significantly associated with recovery.

Table 2 shows the effects of adjusting the model for important covariables in a sequential fashion. Model 1 shows that longer length of stay and older age are associated with reduced odds of regaining ambulatory ability after adjusting for other demographic variables. However, age and length of stay were no longer significant after adjusting for global health measures and specific medical problems (Model 2). As demonstrated by the full model (Model 4), the participants who regained ambulatory ability were more likely to be unmarried, have a longer physician‐rated life expectancy, not have a diagnosis of deep vein thrombosis, not have physical restraints or a urinary catheter in use, and have greater bed mobility at admission.

Predictors that remained significant in the final multivariate model (Model 4) were summed in order to determine the proportion of patients who had one predictor versus those who had more than one predictor. Figure 1 shows the percentage of those who recovered ambulatory ability according to number of predictors, ranging from one to all 6 predictors. The results demonstrate a graded relationship, with number of predictors positively correlated with percentage of those who recovered ambulatory ability (P < .0001).

Figure 1

Patients who died prior to discharge were more likely to be male and have altered mental status, a urinary catheter, restraints, a shorter physician‐rated life expectancy, lower admission bed mobility, and increased severity of illness compared to those who survived. When the 34 patients who died were excluded from the multivariate analysis, the factors predicting ambulatory recovery were unchanged from those reported in Model 4 of Table 2.

DISCUSSION

In this study of older hospitalized patients, approximately 40% were able to regain their ambulatory ability despite being limited to the bed or chair on admission, having significant severity of illness, high level of use of restraints, and functional dependence on admission. Predictors of regaining ambulatory ability were identifiable at hospital admission. These predictors also were correlated with recovery of ambulatory ability in a graded fashion, lending support for the direct relationship between these predictors and recovery.

Physician‐rated life expectancy, a simple assessment that combines a physician's medical knowledge and clinical acumen, was demonstrated in our study to be a better predictor of recovery of ambulatory ability than more elaborate measures like the APACHE II17 and Charlson Comorbidity Index.16 This assessment can easily be done at the bedside and may help to guide discharge planning for the hospitalist physician. Nurse‐rated bed mobility at time of admission, which may reflect aspects of illness severity and cognitive status, was also able to predict recovery.

Of the 6 factors found to be independent predictors of recovery of ambulatory ability, 4 were related to mobility: lack of a DVT diagnosis, absence of a urinary catheter, absence of restraints, and nurse‐rated bed mobility at admission. In the group of patients initially expected to be confined to a bed or chair, those with additional mobility‐reducing factors, such as catheters and restraints, were less likely to recover, even after controlling for illness severity and comorbidity.

Marital status was not found to predict recovery of ambulatory ability in the simple unadjusted bivariate analysis, but after adjusting for other demographic, global health, and disease‐related variables, those who were unmarried were more likely to recover ambulatory ability. These interesting covariate‐adjusted effects for marital status have not been previously reported in the literature. One large study of the impact of marital status on hospital outcomes demonstrated those who were unmarried were more likely to require discharge to a nursing home and had slightly higher hospital costs and longer length of stay.19 Our findings may be related to such patients lacking support other than from themselves, with the possibility of being discharged to a nursing home an incentive to get up and walk.

Although age, race, and previous ADL status were found to be significant predictors in a previous study,12 we did not find this in our sample. This may be because, unlike in other studies, most of our patients had significant functional impairment on admission. The importance of age in our cohort disappeared when illness severity and comorbidities were added to the model.

The strengths of this study include having comprehensive patient‐related data on demographic, illness severity, comorbidity, and hospital‐related factors available, which enabled detailed analyses of predictors for regaining ambulatory ability. In particular, the ability to examine such factors as bed rest and hospital‐related treatments like restraint and catheter use, enabled this study to add significantly to the available knowledge of predictors of ambulatory recovery. The use of nurse interviews to obtain patient‐related data has been demonstrated in previous studies to be a preferred method of collecting data when compared to patient self‐report.20, 21 Examination of these factors in a cohort of patients who would be expected to be at very high risk for remaining bed‐ or chair bound, given their admission activity limitations and functional dependence, is also noteworthy.

Several important limitations deserve comment. Since the data were collected, average length of hospital stay generally has decreased. However, the patient population we studied continue to experience longer hospital stays than functionally intact patients. One recent study demonstrated that the length of hospital stay of patients who were dependent in one or more ADLs on admission was 35% longer than that of those not ADL dependent at admission.22 Seventy‐five percent of those in the present study cohort were dependent in all 7 ADLs and had a mean length of stay of 12.3 days. Despite the longer mean length of stay, 70% of those in the study cohort were discharged within 2 weeks of admission. In the university hospital where this research was conducted, mean length of stay ( SD) in 2004 was 6 8.6 days, but 10% of patients 55 years of age and older remained in the hospital for more than 2 weeks.23 This suggests there continue to be long‐stay patients in the current hospital environment, to which these findings may apply.

Standards of practice, such as for use of restraints, have also changed. In 1992, between 7.4% and 17% of all hospitalized medical patients were restrained, according to a literature review.24 A 1998 survey of 3 hospitals found the prevalence of restraints still ranged from 3.9% to 8.2% and noted that among the most common reasons reported for using restraints were to prevent patient disruption of therapy, to confine confused patients, and to reduce the number of falls.25 Thus, our study cohort would be more likely to be restrained, even in the current hospital environment, given that 43% of the cohort had altered mental status and that most were at risk for falls because of their poor functional status.26

Nevertheless, even though the use of restraints has declined since the data were collected for this study, this should affect neither the internal validity of the results nor the ability to address the question of what factors predict recovery of ambulatory ability. Indeed, the inclusion of patients on whom restraints are frequently used emphasizes the need for continued diligence in creating a restraint‐free environment in our hospitals. Data about the use of physical therapy services were not available in the study. Therefore, it is unknown to what extent the use of these services encouraged ambulation.

In this observational study, we found 6 factors associated with regaining ambulatory ability among hospitalized patients who had significant activity limitations and functional dependence on admission. These findings suggest predictors easily assessed by the hospitalist physician can help to identify those patients most likely to recover ambulatory ability prior to discharge. It also demonstrates the importance of mobility in maintaining function, given that many of the predictors are factors that either impede mobility such as restraints and urinary catheters or measure mobility such as admission bed mobility. Last, recognizing physician‐rated life expectancy as a strong independent predictor of recovery of ambulatory ability should encourage hospitalist physicians to continue to use their greatest tool, their clinical judgment, to determine who will recover ambulatory ability.

As most of these predictors can be identified on admission or shortly thereafter, these factors may be useful in helping physicians and other health care providers to predict the potential patients have to recover ambulatory ability. This information may help physicians identify patients who might benefit from early mobility programs, placement on hospital units where mobility will be enhanced, or the early initiation of discharge planning for those patients identified as unlikely to regain ambulation ability. In addition, addressing factors that are potentially modifiable, such as low bed mobility and the use of urinary catheters and restraints may not only improve the chance of recovering ambulatory ability but would also improve the quality of care provided to older patients.