Dr. Juliessa Pavon, MD: The Power of Objective Patient Mobility Data

Today we speak with Dr, Juliessa Pavon, MD.

Dr. Pavon is a researcher and associate professor at Duke University and is associated with the Durham V. A. for geriatrics. During our conversation, we get into the importance of mobility measurement, and some of Dr. Pavon’s research revolves around using accelerometer data to measure mobility in the hospital. And one of the key takeaways from our conversation really talks about objective data and the best way to use objective data in order to improve clinical practice. Just like many things in life, it is often hard to improve on something until you measure it. And that's something that Dr. Pavon’s research has really highlighted.

Transcript

Drew

00:00:02 - 00:00:59

Welcome to the Mobility Minute podcast. I am your host Drew Martin. Today we speak with Dr. Juliessa Pavon of Duke University Medical Center. Dr. Pavon is a researcher and associate professor at Duke University and is associated with the Durham V. A. for geriatrics. During our conversation, we get into the importance of mobility measurement, and some of Dr. Pavon’s research revolves around using accelerometer data to measure mobility in the hospital. And one of the key takeaways from our conversation really talks about objective data and the best way to use objective data in order to improve clinical practice. Just like many things in life, it is often hard to improve on something until you measure it.  And that's something that Dr. Pavon’s research has really highlighted 

Drew

00:00:59 - 00:01:36

and then taking that measurement and applying it to whether other aspects of hospital care are being conducted appropriately. In Dr. Pavon’s case, she looked at VTE pharmacologic intervention and whether that was properly associated with a patient's mobility status. So I want to thank Dr. Pavon for her time and appreciate her conversation with us here on the mobility minute podcast, - enjoy. 


Drew

00:01:36 - 00:02:22

Hi Dr. Pavon - thanks for joining us today on the Mobility Minute podcast. This is really a place to talk about an underrepresented idea in the hospital of the importance of mobility and how it can improve a lot of aspects of patient care. I know a lot of your research has revolved around this idea of measuring mobility objectively in order to kind of give a bigger picture of what's going on with the patient. So, if you could take us back, let us know what your overall definition of mobility in the hospital, which is something we like to do with all of our guests and then bring us back to your research in 2018. 

Dr. Pavon

00:02:22 - 00:03:16

Well, thank you very much for the opportunity to be here as well. And I'm very excited to talk to you about mobility, especially mobility in the hospital because what we've seen is that patients spend a lot of their time in the bed while they're hospitalized. We've seen other research really support that over 90% of their hospital stay is spent in bed. And that was very striking to me even when I would see patients on round as well, that the majority of our rounds is spent really talking to patients over their bed and very little seeing them up and, in the chair, at least or even up and walking around in the hallways. And that became more evident to me as well when we saw the impact that that would have on their hospital outcomes where so many patients would come into the hospital 

Dr. Pavon

00:03:16 - 00:04:00

being well function living at home. And then now was sudden they are having to be discharged to a skilled nursing facility in part because of the lack of mobility that they had in the hospital. So that was a big motivating piece for why I was interested in mobility, and I would certainly define mobility in the hospital as activity that really takes the patients from a lying position, even up to a sitting position that would still count as mobility, mobility from the bed to the chair certainly counts. But even if we were to talk to a specialist like physical therapists and occupational therapists, they would say that really mobility is even more than that, which is actually getting 

Dr. Pavon

00:04:00 - 00:04:17

walking activity in as well. So walking activity is a very important piece of mobility and that it's not just walking activity in the room, but actually walking activity outside of the room into the hallway. That that's really where we want to see mobility happening as well. 

Drew

00:04:17 - 00:05:07

Right. And that's interesting because you talk to 10 people, you get 10 different answers on what mobility in the hospital should look like. And a lot of people say that it's you know, maybe just walking, but like you said, there's a lot of levels to it and so kind of understanding what those levels are and being able to make sure that a patient is progressing all the way to that final stage of walking and being able to get back to that pre-hospital status. I feel like it is crucial. So, what led you to notice these gaps in how mobility was being addressed in your hospital or your system and be able to take that into your research and start finding these accelerometer based wa ys of measuring mobility. 

Dr. Pavon

00:05:07 - 00:05:52

It's a great question. So I think part of what happened is that in talking to patients we would certainly ask the patients, have you gotten out of bed today? And a very simple answer sometimes is yes, but other times it's no, but even with the yes, that still doesn't say enough. You know, really how much they were able to get out of bed. And so we follow up the question well, how much walking were you able to do for instance or how much time did you spend in the chair? And again, very general answers very vague. Some patients can't really recall the amount of time that they spend up in the chair or walking. And we thought that that was still a very important part of their recovery process to actually know 

Dr. Pavon

00:05:52 - 00:06:32

how much time someone is spending out of bed or walking. We would then dig into the chart to try to find out from a P. T. note, for instance, or a nursing note. And it also became difficult to consistently find that information in the chart. And so there was this more and more awareness of the need for some objective measure of mobility. And also when we would ask for instance, nursing pt you know, and even other providers about mobility, the spectrum of answers was very varied. It could be anything from the patient walked a lap or the patient spent, you know, 

Dr. Pavon

00:06:32 - 00:07:25

10 minutes walking or the patient walked 100 ft. You know, that's all those are all very different types of answers. And again, speaking to the way that the data around mobility is very unstructured, not objective and that all became more clear that there was a need to measure mobility and one objective way of measuring mobility certainly is with the use of wearable devices. And we specifically focused on the use of research grade wearable devices like accelerometers. There certainly could be consumer grade type of wearables with Apple Watches and um Garmins and things like that. But we wanted something that we could really use that have been certainly validated, for instance, even in the hospital population as well. So we stuck with the research grade monitors.

Drew

00:07:25 - 00:07:51

And I guess the hospital patient is unique in the fact that their gait speed is going to be slower. They're not as quick to move. And we know that these accelerometers that are in the consumer grade technology are not 100% accurate all the time. You know, you moving your wrist around. So how did you go about validating this tool for the hospital patients specifically? 

Dr. Pavon

00:07:51 - 00:08:39

That's a great question because you bring up a good point about how mobility in the hospital very different certainly from ability that outpatient setting. And we found that to because for instance, there's a slower gait speed a lot of times, there's more of a shuffling gait and a lot of our patients to so we did want to look for monitors that had taken some of those features into account. And we settled on the Actigraph monitor to do a lot of our mobility data. And it was a Bluetooth monitor as well with a three axle accelerometer built in so it could get some sense of positioning as well. And we found that to be a very valuable way to measure objective mobility. And really the striking part that we found is that 

Dr. Pavon

00:08:39 - 00:09:10

the mean number of the median number of steps really that patients were taking during their hospitalization a day was A little bit under 1300 steps a day. And certainly, that speaks to again the minimal amount of mobility that is occurring in the hospital with a range of anything from 200 steps a day to 6000 was the most, you know, the highest range that we found. But certainly that was consistent with what other literature has shown around mobility in the hospital. 

Drew

00:09:10 - 00:09:32

Right. And going back to that 2018 article that you published talking about pharmacologic VTE intervention and relating it back to mobility. Where is that correlation found? Or where in your research did you find this connection between VTE. Prevention and mobility? 

Dr. Pavon

00:09:32 - 00:10:22

Right. And that was a unique study that actually combined wearable data with someone's EHR data because we placed monitors on patients’ ankles and wrists and then had that monitor in place during through the duration of their hospital stay for up to seven days during their hospitalization. And then we looked at the patient record to see what type of VTE Prophylaxis orders they had been receiving during that time. So we were looking at the start date for the VTE prophylaxis and the end date and VTE prophylaxis was anything related to the heparins or, the Lovenox medications, pharmacological VYE prophylaxis as well as mechanical VTE prophylaxis. So we were looking for 

Dr. Pavon

00:10:22 - 00:11:12

the sequential compression device orders also. And what we found was that even for the patients that were moving the most in the hospital. So you know that 4,000 5000 steps a day range their length of time with pharmacological VTE prophylaxis was just as long as the person that was moving with the fewest number of steps a day. And that is not what we would have wanted to see because the guidelines certainly recommend that for patients that are up and moving, who have mobility that VTE prophylaxis can be shortened. And so we would have wanted to see that those with the highest number of step counts would have had the shortest days in prophylaxis use.

Drew

00:11:12 - 00:11:43

Right. And that makes sense as a patient starts to walk and they start to have their calf pump the blood back up to their heart for them they don't necessarily need to rely on that pharmacologic intervention and blood thinning because of the possible side effects that that can have. So how does the typical patient get assessed for their pharmacologic VTE intervention and when did they decide to kind of wane them off that pharmacologic? 

Dr. Pavon

00:11:43 - 00:12:44

Definitely. The guidelines do vary around whether a patient is a general medical patient versus a surgical patient. But overall there is a recommendation to use VTE prophylaxis especially when someone is medically ill and always and surgically ill as well. And the main recommendations around pharmacological VTE prophylaxis. And there is recommendations even to risk stratify using risk stratification scores such as the Padua risk stratification or the Caprini risk stratification as well as even taking into account the risk for bleeding as well. And that's where mechanical VTE prophylaxis becomes very important because there are a lot of you know, a good number of patients who have risk for bleeding, especially post-surgery as well or for other medical reasons. And so the use of mechanical VTE prophylaxis is also important. 

Dr. Pavon

00:12:44 - 00:13:08

Then once someone is considered to be a candidate, certainly for VTE prophylaxis, there are certain recommendations around the duration of use, but regarding mobility, there's the recommendation that the duration of use can be shorten once the patient is up and mobile as well. And so, and that's where we were trying to correlate mobility with duration of use. 

Drew

00:13:08 - 00:13:29

And that makes sense to not overindulge the drug just to give it, but instead to assess where the patients at and then appropriately administer it based on that. So what is the importance behind mobility measurement even for the most various of patient types? Why is it important to measure mobility? 

Dr. Pavon

00:13:29 - 00:14:23

Yes, I think the main reason why I feel it's important to objectively measure mobility through something like a wearable devices because then it gives more awareness to the provider about whether the patient is actually moving or not moving because in relation to VTE prophylaxis, for instance, if a provider feels that the patient is more bedridden they are more likely to continue the VTE prophylaxis where in fact if they objectively know that the patient is actually not as bedridden as they thought that might then prompt them to not maintain the VTE prophylaxis as long. The converse is also true - a provider might assume that the patient is moving more 

Dr. Pavon

00:14:23 - 00:14:57

than they are, so that could also lead to under prescribing of VTE prophylaxis if they incorrectly make that assumption that the patients actually moving out of bed and so having something more objective can be very valuable. And we did do, you know, interviews even with providers and patients in terms of how, what type of information they would want about their mobility. And there was a lot of interest in knowing certainly the step counts but also the amount of time that someone spent out of bed and moving as well. 

Drew

00:14:57 - 00:15:14

That was my next question of what metrics were important to you guys because obviously finding that standard to which you measure mobility is so crucial, but then understanding what's going to be important for the caregiver to get a picture and understand what's going on with the patient too. 

Dr. Pavon

00:15:14 - 00:15:58

Exactly yes. And I would see the literature was more consistent around step counts. And even the thought that there's thresholds for the number of steps that someone should take in order to prevent functional decline in the hospital. And that threshold is somewhere around 1100 steps a day in the hospital can prevent functional decline. So I would say step down is still one of those metrics and then also a position and time spent in that position out of bed. So it was very, even though some patients might not fully make it, you know, out of the bed and into the chair, but there is definitely still a difference between being flat, you know, laying down flat, not moving to at least spending, sometimes sitting up in the chair 

Dr. Pavon

00:15:58 - 00:16:13

and making that distinction is very sometimes difficult piece for some of these wearable devices to make that distinction. But it became known that it was that it was important for providers to at least know that they were sitting up at some point. 

Drew

00:16:13 - 00:16:46

And I think getting that mobility picture um is so important, and there's a lot of stakeholders whether your physical therapy and you're seeing the patient one time every three days or if you're a nurse and you see them every day, you want to have that snapshot of what's going on to patient just so that you know what the best intervention is going to be. So, what's the follow up with these findings through the research? Are you just going to strap accelerometers on every patient just a to see what they're up to or what’s the next step after this. 

Dr. Pavon

00:16:46 - 00:17:27

One of the big barriers with wearable data is getting that report of the mobility out to the providers and being able ideally to link it in with the EHR. Some of the research grade monitors would unfortunately (have) a step in between where the data must be processed and then potentially then somehow reuploaded back into the EHR. And that feels clunky and may not be really feasible and in the real-time setting. So, there is certainly interests around wearable consumer grade data that might have an opportunity to link 

Dr. Pavon

00:17:27 - 00:18:07

in more directly to the EHR. So I think that's always a very valuable piece. But I think what we've learned the most through a lot of this work is that even if we were to strap an accelerometer on every patient and that data was available, there's still a lot that needs to be understood on how the end user would use that data. So how would the physician change their clinical management, knowing how much the patient is moving? How would it change nursing workflow? How would it change PT/OT workflow? And when we did start to do a deeper dive in understanding that we found that there was a big 

Dr. Pavon

00:18:07 - 00:18:59

impact on the culture of mobility in the hospital. And what we found is that there is still such a big drive to minimize, you know, a lot of mobility because of this ‘falls never event.’ That is a federal quality mandate in the hospital where really the goal is to have no (patient) falls in the hospital. That is driving a lot of the culture around mobility. So even if patients and providers would know how much they were walking, would it really change the nurse being willing to move the patient out of bed if there's still all this concern around falls as a never event. So what we're realizing is that we're focusing on 

Dr. Pavon

00:18:59 - 00:19:29

implementing redesign of mobility in the hospital with the focus of changing some of that culture around mobility. And there's a lot of great research and literature around these interventions that are focused on changing kind of that culture around mobility in the hospital. I would say that’s the main next step, and then using objective mobility within those types of interventions that are being developed to promote mobility in the hospital. 

Drew

00:19:29 - 00:20:02

It seems like to me at least that mobility just like a lot of things in life if you don't measure it, it's hard to change it. We know the underlying reasons of why these hospital patients are immobile - they're very ill in a lot of cases. But truly how do you change something unless you have an idea of what is going on in the first place? There are plenty of examples of this in other industries and in healthcare, but that's definitely the case, right? Or am I missing something? 

Dr. Pavon

00:20:02 - 00:20:57

That's right. A big part of the culture change is around documenting mobility. So even without having a widespread objective measure of mobility, at least there is this idea that some standardization needs to occur. So, for instance, building in the HER flow sheets that will capture at least how many steps did PT record that somebody walked or what was the distance or what was the amount of time something that standardized. But that decision still must be within the institution to make it (happen). For example – are we going to measure mobility through steps? Are we going to measure it through time out of bed? All of those discussions definitely need to occur. But for sure, even just documenting something that in a standardized way is really part of the culture change, 

Drew

00:20:57 - 00:21:40

And that communication and understanding of what the patient's mobility status doesn't necessarily fall all on the shoulders of PT. You have other bedside caregivers, such as nurses, patient care technicians - all of these stakeholders who really should have a part in this patient mobility journey. And you talk a little bit about communication in your 2018 article, especially when it comes to documentation in the EHR. You say that you only found 52% of patients had any sort of walking documented in the EHR. So what does that tell you? Obviously, that's not to the level of which it should be. Is that correct? 

Dr. Pavon

00:21:40 - 00:22:08

First three days of being in the hospital, very few patients have any data around mobility because it's usually around day 3 when PT and OT are consulted, and then you start to get documentation of mobility. So for the first three days when it's a very critical period of a patient's hospital today, there's very little information about mobility. And once those three days pass, you get some people who are getting 

Dr. Pavon

00:22:08 - 00:23:01

PT and OT consults for instance, is only 50% which means that you have, you know, half of the rest of the older adult population with little to no standard documentation about mobility in the hospital. And it becomes very challenging for the providers to make clinical decisions around their hospital care, which VTE prophylaxis is one of those very key parts of the hospital stay, and that depends on certainly the amount of mobility that is happening. There are other pieces as well. You know, minimal mobility can contribute to delirium, it can contribute to a longer length of stay, to functional decline in the hospital and then requiring a higher level of care after discharge. So that's why that becomes very critical that for three days essentially providers are kind of driving with blinders on. 

Drew

00:23:01 - 00:23:29

Yeah, exactly. That is scary situation considering those are some of the most critical days in the hospital that there is essentially no data that is currently collected. Especially some of those smaller victories such as the dangle at the bedside or just setting up. These are things that you feel like most clinicians would want to know about their patient considering the impacts that immobility and a lack of movement can have. 

Dr. Pavon

00:23:29 - 00:24:28

That's why I definitely like a lot of the work that your group is doing around trying to capture mobility in an objective way throughout the hospital with using medical devices. Because that would certainly be one way of capturing objective mobility is through other devices that patients are already having to wear. And then the low hanging fruit would be a culture change around documentation. So for instance, there's a big focus in our institution in having nursing participate in some of that documentation around mobility and being able to screen for mobility using a bedside mobility assessment tool. There's also other tools like an AMPAC that other institutions are using  - but having that be part of the structured daily work up for a patient 

Dr. Pavon

00:24:28 - 00:24:51

is incredibly valuable. And then having a way that that structured work up can be then documented in the EHR becomes the second piece, and that's where a lot of our focus has been around that screening from mobility on a daily basis and then having a way that is easily documented in the EHR that can be viewed by all other providers on the team. 

Drew

00:24:51 - 00:25:28

Awesome. Well, thank you Dr. Pavon for coming on today to talk a little bit about this topic of mobility and how it relates to pharmacologic intervention and documentation. I think your work really stood out as it relates to some of the initiatives we've been trying to communicate through this podcast, but it's also important to give some shine to thought leaders like yourself in order to gauge your opinion on why mobility is so important in the first place to really help drive that culture change that we were talking about. So I thank you for your time and all the work that you've done and I appreciate you being with us here on the Mobility Minute podcast. 

Dr. Pavon

00:25:28 - 00:25:43

It has been my pleasure, and this is a topic that I really am excited about. So, and I'm hoping to make a change in the difference in how we practice around mobility in the hospital. 

Drew

00:25:43 - 00:25:53

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