Jo Ann Brooks, Ph.D, RN, FAAN, FCCP: The Burden of Patient Immobility on Hospital Quality & Safety

Today we speak with Jo Ann Brooks.

 Jo Ann (Ph.D RN FAAN FCCP) is a quality and safety consultant who’s been in healthcare for over 45 years.  She retired from IU Health, a multi-hospital healthcare system based in Indianapolis, Indiana, at the end of 2018 where she was System VP of Patient Safety and Quality. She currently consults for healthcare organizations, pharma, and medical technology in the areas of healthcare safety and quality, CMS Pay for Performance, and prevention of non-ventilator hospital acquired pneumonia.   

Transcript

Today we speak with Jo Ann Brooks.

 Jo Ann (PhD RN FAAN FCCP) is a quality and safety consultant who’s been in healthcare for over 45 years.  She retired from IU Health, a multi-hospital healthcare system based in Indianapolis, Indiana, at the end of 2018 where she was System VP of Patient Safety and Quality. She currently consults for healthcare organizations, pharma, and medical technology in the areas of healthcare safety and quality, CMS Pay for Performance, and prevention of non-ventilator hospital-acquired pneumonia.   

Hi Jo Ann, thanks for taking some time to share with our listeners the link between mobility and safety. To kick things off… can you give us a brief overview of the importance of safety & quality in the hospital for those who have no clue what we’re talking about?  

I think the modern age of safety and quality for hospitals started after the publication of To Err is Human in 1999 by the National Institutes of Health and in 2001, Crossing the Quality Chasm published by the Institutes of Medicine. With these two publications the public became very aware of problems that were happening in the hospital and it was also a wake-up call for hospitals to begin to examine their own quality and safety. As the hospitals became more focused (in this area) so did the Centers for Medicare and Medicaid Services (CMS). At this same time, the Agency for Healthcare Research and Quality began publishing the patient safety indicators, which we still use today. In 2005, ten measures were required for hospitals to have, which is called Pay for Reporting. Those measures related to mortality, HCAHPS patient satisfaction data, and the surgical care improvement project. Today there’s a multitude of measures that hospitals are required to report to CMS.

I think that quality departments are key in hospitals for abstracting, interpreting, and communicating data and developing quality improvement projects to improve the safety and quality within a hospital setting. In addition to CMS looking at quality, over 95% of third-party payers also have quality measures that they require hospitals to report. Also, boards of directors are responsible for the quality and safety of a hospital and you’ll find that it is either the #1 or #2 item on every agenda.

Now, we know there are links between mobility and some of the focus around safety and quality. How does patient immobility directly affect costs for a hospital?

The consequences of immobility are enormous for the patient. If we think about immobility, it really impacts every system of the body. One article that I read just recently talked about decreased functional status which occurs in the hospital setting due to immobility can be described as a functional disability in the hospital. There are numerous complications associated with immobility: ventilator/non-ventilator-acquired pneumonia (HAP), hospital-acquired pressure injury, falls, venous thromboembolism (VTE), and delirium. Also, hospitals with patients who have immobility may have increased length of stay and hospital readmissions can be related to immobility. 

The cost to hospitals and our healthcare system is huge. 

So what am I missing here? It seems like mobility ought to be considered in the conversation to see some of these massive costs dwindle. What has led to this culture of immobility and why are people hesitant to get these patients up out of bed?

The culture of immobility, sadly, has been cultured over time. Everyone knows that mobilizing and ambulating patients is fundamental to patient care, but I think as healthcare has become complex and we have more technology, unfortunately mobilizing and ambulating patients has fallen down on the priority list. We need to consider mobility and ambulating patients as a treatment, not just something to check off. It really is a treatment to prevent other complications and problems within the hospital setting. 

When we look at pharmaceuticals, sometimes nursing looks at a patient getting enoxaparin to prevent a VTE and thinks, “Ah we’re taking care of that VTE,” but in fact that treatment is just part of that prevention. Mobility is another intervention that needs to go along with it.

We know that today physical therapy is in great demand. They don’t have the time to evaluate every patient and help with ambulation so I think all of the mobilization efforts then fall on the nurses’ shoulders, but that accountability can also fall to others to help.

Exactly - because the quality of life is the ultimate goal for patient recovery, right? And without a baseline, it can be hard to gauge the recovery status of a patient. What is functional status? And why is it important to measure before, during, and after a hospital stay?

You’ll find several definitions of functional status and tools in the literature. Oftentimes those tools are looking not only at how that patient can mobilize, but also looks at emotional status and quality of life in multiple ways. When we look at functional status in light of mobility, we look at that patient’s ability to get up and move independently.  

I think we do need a way to discretely measure functional status. When we talk about mobilizing patients from the time they come into the hospital, we need to know what they’re doing preoperatively or pre-hospital setting. Then we need to measure throughout the hospital stay to determine by the time we’re ready to discharge that patient if they are back to where they were with their functional status before they came in. 

It’s a disservice to patients to have them leaving the hospital in worse shape than they came in. Immobility is a part of that problem. 

Well Jo Ann I want to thank you for your time today. I think we got some good insight into the key motives behind safety and quality and how a focus on mobility can really change the narrative from increased risk to advanced recovery. So again, thank you very much.