The importance of patient ambulation: Ensuring quality and best practices in the postoperative wards

Enhanced recovery after surgery (ERAS) protocols were introduced in the 1990s in an effort to identify and implement strategies and interventions designed to improve recovery and outcomes following surgical procedures.¹

Patient and clinician walking in a hospital

While some ERAS practices are controversial, early mobility after surgery has been consistently associated with shorter hospital stays and faster recovery to baseline functional status.^2–4 Early ambulation after surgery has many benefits. The effects of early ambulation after lower-extremity joint surgery in particular are dramatic.⁵ Two recent studies that examined the impact of early ambulation—defined as being out of bed and walking on the same day as the surgery—in patients after knee and hip arthroplasty reported shorter hospital stays and as much as US$3,000 in savings per day when compared to among those demonstrating late ambulation (i.e., walking on the first postoperative day).^6,7

While it is intuitive that early ambulation is beneficial and promotes greater cost-efficiency among patients undergoing ambulation-related procedures, the impact of early ambulation is not limited only in those receiving these operations.⁵ Studies looking at elderly patients admitted for a wide range of nonorthopedic conditions suggested that higher amounts of ambulation were associated with reductions in the hospital length of stay of up to two days.⁸ Another study assessing intensive care patients with acute respiratory failure revealed that patients who were out of bed earlier (five vs. eleven days) experienced shorter intensive care unit stays and were discharged from the hospital up to 3.3 days earlier.⁸ These are significant findings that indicate not only better clinical outcomes but also substantial cost-savings relative to those incurred by immobile patients requiring longer hospitalizations.

The implementation of quality improvement programs to promote patient ambulation and mobility does not have to be labor-intensive. Studies have suggested that any work conducted in developing and implementing such quality improvement plans is offset by the resulting improvements in patient outcomes and reductions in health care resource utilization.⁹

While studying the impact of ambulation on patient outcomes, the Physician–Patient Alliance for Health and Safety found that increasingly unmanageable nursing workloads represent an alarming but pertinent barrier to early mobility.⁵ Evidence reveals that steady increases in nursing responsibilities have led to severe limitations in the amount of time they can spend encouraging and assisting individual patients to ambulate, with nurses spending, on average, only 30 minutes per patient per 10-hour shift.¹⁰ Current monitoring technology is partly to blame for nursing workload excesses and patient immobility. As Hanneman noted, “at times, current patient monitoring technology contributes to the development of complications because it hampers patient movement.”⁵

In a survey conducted in 2014, nurses were asked to report what technologies they felt would help them to care for patients the most, with 80% of respondents indicating that they wanted monitors that were wearable and wireless, facilitating greater patient mobilization and a more streamlined workflow.¹¹

The push for enhanced recovery after surgery is here to stay, with a proven track record of reducing postoperative complications and hospital length of stay.¹ Early mobility is a large part of this campaign. Mobile patients present a challenge for nurses and other clinicians when it comes to monitoring and assessing their progress and condition. Recent advances in technology have led to a range of small, wearable sensors capable of measuring, storing, and transmitting large amounts of patient and environmental data.^12,13 A recent study specifically looking at continuously monitoring physical activity showed that wearing a feedback-enabled physical activity monitor improved leg pain and walking distance among patients with peripheral vascular disease.¹⁴

The benefits of hospital inpatient ambulation are clear. With the potential to improve care outcomes, reduce the hospital length of stay, and minimize the occurrence of postoperative complications, it is essential that patients get out of bed. As noted, keeping an eye on ambulatory patients has its own challenges. Traditional monitors tether patients to their beds and existing wireless technologies are not reliable enough to relay continuous data through walls and over longer distances.¹⁵ Emerging technology such as the GE HealthCare’s Portrait™ Mobile continuous monitoring system is able to overcome these shortcomings by incorporating small wearable monitors that connect to a robust and reliable network, taking advantage of edge computing capable of processing large amounts of continuous patient data. Most importantly, systems like the Portrait Mobile allow ward patients the freedom to move about and more easily participate in the physical therapy that is vital to their recovery. As this technology makes its way into hospitals, we hope to see improvements in patient outcomes, more adherence to ERAS protocols, shorter hospital stays, and greater cost-savings due to more effective resource utilization.

References

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Kwasnicki RM, Hettiaratchy S, Jarchi D, et al. Assessing functional mobility after lower limb reconstruction: a psychometric evaluation of a sensor-based mobility score. Ann Surg. 2015;261(4):800–80 DOI: 10.1097/SLA.0000000000000711. Accessed December 5, 2019.
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Normahani P, Kwasnicki R, Bicknell C, et al. Wearable Sensor Technology Efficacy in Peripheral Vascular Disease (wSTEP): a randomised clinical trial. Ann Surg. 2018;268(6):1113–1118. DOI: 10.1097/SLA.0000000000002300. Accessed December 6, 2019.
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