You are on page 1of 8

Clinical Nurse SpecialistA Copyright B 2012

Wolters Kluwer Health | Lippincott Williams & Wilkins

Feature Article

Impact of Early Mobilization Protocol on the

Medical-Surgical Inpatient Population
An Integrated Review of Literature
Lavanya Pashikanti, MSN, RN n Diane Von Ah, PhD, RN

Purpose/Objectives: stay in patients with community-acquired pneumonia, and

The purpose of this review article was to examine the efficacy of maintained or improved functional status from admission to
an early mobilization protocol in hospitalized medical-surgical discharge of hospitalized older adults and patients recovering
inpatient population. from major surgery.
Background/Rationale: Interpretation/Conclusion:
Prolonged immobilization can result in functional decline Overall, our review found that early mobilization (especially
and heighten the risk for hospital-associated complications early ambulation) of the medical-surgical inpatient population
such as falls and pressure ulcers. Early mobilization, on the may improve patient outcomes.
other hand, has been shown to prevent functional decline Implications:
and hospital-associated complications. However, currently Our review indicated that the greatest impact of early
no evidence-based guidelines exist with regard to an early mobilization is through standardized mobility protocols or
mobilization protocol for the medical-surgical inpatient population. programs. Clinical nurse specialists are experts in leading
Therefore, the purpose of this review was to provide a thorough and sustaining standardized protocols or programs
analysis of current evidence pertaining to an early mobilization pertaining to a nurse-sensitive outcome such as mobility.
protocol for the medical-surgical inpatient population. KEY WORDS:
Methods: early mobilization, medical-surgical patients, outcomes
A comprehensive search of the literature was conducted

using Ovid, MEDLINE, and PubMed databases using ospitalization, especially among the elderly, can
the following search terms: early ambulation, postoperative result in decreased mobility and functional de-
care, and length of stay. cline. Decreased mobility during hospitalization,
Outcome: in turn, can lead to accelerated bone loss, dehydration,
We found a total of 9 empirical studies that met the inclusion malnutrition, delirium, sensory deprivation, isolation, sheer-
criteria. Studies revealed that using the basic tenets of an early ing forces on the skin, and incontinence.1 Functional
mobilization protocol was associated with improved outcomes decline (defined as the inability to perform usual activities
for patients with deep vein thrombosis, reduced length of of daily living due to weakness, reduced muscle strength,
and reduced exercise capacity) can also significantly im-
pact nurse-sensitive outcomes.1 This is especially true for
Author Affiliations: Medical-Surgical Clinical Nurse Specialist, Indiana
University Health Bloomington (Ms Pashikanti), and Assistant Professor the elderly population, which constitutes nearly half of
and Robert Wood Johnson Nurse Faculty Scholar, School of Nursing, the medical-surgical inpatient population. In fact, func-
Indiana University (Dr Von Ah), Indianapolis, Indiana. tional decline has been identified as the leading com-
Support for this publication was provided in part by a grant from the plication of hospitalization for the elderly.1 Functional
Robert Wood Johnson Foundation (Nurse Faculty Scholar Award [prin-
cipal investigator Dr Von Ah 64194]). decline and deconditioning from a patients baseline mo-
The authors report no conflicts of interest. bility status can occur as early as day 2 of hospitalization
Correspondence: Lavanya Pashikanti, MSN, RN, 1063 S Colchester of elderly patients.1 Without adequate mobilization, an in-
Ct, Bloomington, IN 47401 ( dividual can lose up to 5% of muscle mass daily.2 This loss
DOI: 10.1097/NUR.0b013e31824590e6 in muscle mass and strength can have a significant impact

Clinical Nurse Specialist A 87

Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Feature Article

on nurse-sensitive outcomes such as hospital-acquired comes measured, and findings of each empirical study.
pressure ulcers and falls. Falls and hospital-acquired pres- Overall, our review found that early mobilization (espe-
sure ulcers can lead to further debilitation for the patient, cially early ambulation) of the medical-surgical inpatient
as well as increase the length of stay of the patient and population may improve patient outcomes. Specifically,
increase healthcare costs, as much as $17 483 per case3 we found that early mobilization was associated with im-
and $43 180 per case,4 respectively. Research also sug- proved outcomes for patients with deep vein thrombo-
gests that approximately 34% to 50% of the elderly popu- sis (DVT), community-acquired pneumonia (CAP), older
lation who are hospitalized experience functional decline adults, and patients recovering from major surgery. We
that affects the length of stay, mortality, nursing home will summarize these findings in the following sections.
placement, healthcare costs, and readmission rates.5,6
Therefore, clinical nurse specialists (CNSs) must focus their Improved Outcomes of Patients With DVT
efforts to develop intervention protocols that promote One of the earliest studies found to address the basic te-
mobility and prevent functional decline to optimize nurse- nets of an early mobilization protocol in the medical
sensitive outcomes in the hospitalized patient. population included patients with DVT. Partsch and
Early mobilization has been suggested as one effective Blattler22 in 2000 and Partsch et al25 in 2004 revealed that
nursing intervention to prevent immobility-related compli- early ambulation can improve outcomes for patients diag-
cations and promote positive patient outcomes.6Y8 Early nosed with DVT. Partsch and Blattler22 conducted a
mobilization includes the movement of the patient ranging randomized controlled trial in which 45 patients diag-
from passive range-of-motion exercises to active ambula- nosed with DVT received low-molecular-weight heparin
tion, depending on the physical capabilities of the patient, and compression but differed in whether they performed
and is initiated within 24 hours of admission into an acute early ambulation. These researchers found that participants
care setting. Current research has documented the positive who performed early ambulation exercises had lower over-
effects of early mobilization in critical care patients,9Y11 all pain scores and a significant reduction in leg swelling
stroke patients,12Y14 and patients who have undergone (lower leg circumference). The early ambulation group re-
cardiovascular15Y17 and orthopedic surgeries.18Y20 However, ported significantly improved clinical symptoms including
these patients make up a limited number of all potential pa- less pain during walking, reduce pain associated with the
tients cared for in a hospital setting. In fact, critical care units sole of the foot, and the palpation of the foot. In addition,
comprise only 10% of all acute care hospital beds.21 Thus, this group had less subfascial edema, prefascial edema, a
what is not well known is: What impact does early mobi- lower skin temperature, and reduced redness/cyanosis of
lization have on nurse-sensitive outcomes in the hos- the affected limb compared to participants who did not
pitalized medical-surgical inpatient population? Therefore, perform early ambulation. In 2004, Partsch and col-
the purpose of this review and synthesis of the literature leagues25 conducted a long-term follow-up study of 37 of
was to examine the efficacy of early mobilization in hos- the 45 original medical patients. In this follow-up study,
pitalized medical-surgical inpatient population. Findings although not statically significant, a lower percentage of
from this review may be used by CNSs to improve care patients in the early ambulation group had swelling (in-
guidelines and subsequently promote positive outcomes creased leg circumference) in the affected limb (16/26
for the medical-surgical inpatient population. early ambulation group vs 9/11 in the bed-rest group)
than those patients in the usual care unit. In addition, a
SEARCH STRATEGY significantly lower percentage of patients in the early am-
A comprehensive search of the literature was conducted bulation group (18/26 vs 2/11 in the bed-rest group) had
using Ovid, MEDLINE, and PubMed databases. Key terms symptoms associated with postthrombotic syndrome (a
used in this search included early ambulation, postopera- significant complication of DVT) than those patients in
tive care, and length of stay. A total of 9 empirical studies the control group. Consequently, these 2 medical studies
met the inclusion criteria including having been published revealed that implementing the basic tenets of an early
between the years of 2000 and 2011, empirical quantita- mobilization protocol for DVT patients assisted in symp-
tive studies, and in the English language (Table). Of the tom control, in turn maintaining functional well-being.
9 empirical studies, 4 studies included surgical popula-
tions,2,24,28,29 and 5 studies included participants with Reduction in Length of Stay for Patients With CAP
medical diagnoses.22,23,25Y27 In 2003, Mundy and colleagues23 conducted a study in
which they evaluated the effect of an early mobilization
SYNTHESIS OF FINDINGS protocol on length of stay of patients with CAP admitted
The (Table) comprehensively presents the study de- to 3 hospitals in Midwestern United States. These re-
sign, sample population, a detailed description of the searchers conducted a randomized controlled trial in
type of early mobilization intervention protocol, out- which medical units (within each of these 3 hospitals)

88 March/April 2012

Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Table. Comprehensive Review of the Literature Regarding Early Mobilization on
Outcomes in Medical-Surgical Patients
Study Design, Early Mobilization Outcome
Authors/Year Study Purpose Sample/Setting Protocol Variables Findings

Partsch and To evaluate the Randomized controlled 2 Ambulatory Pain: The daily walking
Blattler22 benefits of trial (RCT) groups; 1 with distance was between
(2000) compression and inelastic Unna boot 600 and 12 000 m
(medical early walking Sample: n = 45 patients bandages, 1 with -Overall pain in the ambulatory
study) exercises, in with DVT (15 per group) elastic compression groups and averaged
comparison Setting: Vienna, Austria stockings vs bed -During walking 66 m in the bed-rest
with bed rest rest, no compression group
in acute stage -Sole of foot
of proximal -Calf with palpation Lower overall pain
deep venous scores in ambulatory
thrombosis (DVT) Edema groups (starting
-Leg circumference 2nd day) compared
with bed-rest group
-Subfascial Decreased overall leg
circumference in
-Prefascial ambulatory groups
Skin temperature compared with
bed-rest group
Redness/cyanosis Improvements noted
in specific pain scores
Length of stay (LOS) (during walking, sole
of foot, and calf),
reduced edema
(subfascial and
prefascial), decreased
skin temperature,
and redness/cyanosis
No significant
difference in
progression of
thrombi noted
between groups
Mundy et al23 To determine Group randomized trial EM: Sitting out LOS Reduced LOS
(2003) if early of bed or ambulating (decreased by 1.1 d;
(medical mobilization Sample: for at least 20 min 95% confidence
study) (EM) reduces Total n = 458 during the first 24 h interval, 0.0Y2.2 d)
hospital length
of stay in Intervention: n = 227 Progressive
patients mobilization
Control: 231 occurred each
with CAP
Setting: Midwestern US subsequent day
Raue et al To compare Nonrandomized Multimodal Pulmonary function FAC pulmonary
(2004) outcomes of comparative cohort intervention (forced vital capacity function significantly
(surgical patients study with enforced [FAC]) improved on the 1st
study) receiving mobilization (early day for intervention
a multimodal Sample: ambulation) epidural Duration of group
fast-track analgesia and early postoperative ileus
rehabilitation Total: n = 52 oral feeding Pain Oral feeding and
program vs defecation occurred
usual care Intervention: Fatigue earlier in the
of patients n = 23 (post-AMP) Morbidity and mortality intervention group
laparoscopic Control: LOS No changes in pain
sigmoidectomy scores
n = 29


Clinical Nurse Specialist A 89

Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Feature Article

Table. Comprehensive Review of the Literature Regarding Early Mobilization on

Outcomes in Medical-Surgical Patients, continued
Study Design, Early Mobilization Outcome
Authors/Year Study Purpose Sample/Setting Protocol Variables Findings

Significantly lower fatigue

reported by participants in
the intervention vs control
Morbidity same for both
Intervention group
participants were discharged
significantly earlier than
those in usual care (4th vs 7th
day postoperatively)
Partsch et al25 To investigate Observational cohort See protocol in Clinical and No significant differences
(2004) the long-term study Partsch and venous duplex venous duplex
(medical benefits of Blattler22 investigation and pain
study) compression and Sample: Pain
early walking Total: n = 37 Leg
exercises in circumference,
comparison clinical
vs bed rest
in patients Intervention: n = 26 PTS: 5 symptoms Smaller proportion of
with DVT and 6 objective mobile patients
Control: n = 11 indicators (16/26) had increased
leg circumference
(in diseased leg) vs bed-rest
patients (9/11)
Setting: Vienna, Austria Larger proportion of mobile
patients (18/26) had no
postthrombotic syndrome
(PTS) symptoms compared
with bed-rest patients (2/11)
Marzen-Groller To examine the Comparative pre-post AMP, which includes Functional Researchers found that the
et al2 (2008) relationship of study observational study early and progressive mobility AMP protocol increased the
prolonged LOS mobilization functional mobility of the
and functional Sample: LOS participants
mobility Total: n = 44
status after
lower-extremity Intervention: No difference in LOS was
amputation, and noted.
n = 14 (post-AMP)
the impact of
the Amputee Control:
n = 30 (pre-AMP)
Protocol (AMP)
Setting: United States
Padula and To determine the Nonequivalent control Nurse-driven mobility Functional status Functional status (ability to
Baumhover26 impact of a group design protocol included perform activities of daily
(2009) nurse-driven (controlled trial) promotion of mobility living) scores improved
(medical mobility protocol (question orders for significantly from admission
study) on functional Sample: n = 50 older bed rest); reduction of LOS to discharge in the
decline in adults, variety of medical barriers to mobility intervention group vs control
hospitalized diagnoses (remove catheters);
older patients Setting: United States ambulation 3Y4 Intervention group had
times per day; and up significantly lower LOS
for meals than control (4.96 d
treatment vs 8.72 d,
respectively, P G .001)


90 March/April 2012

Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Table. Comprehensive Review of the Literature Regarding Early Mobilization on
Outcomes in Medical-Surgical Patients, continued
Study Design, Early Mobilization Outcome
Authors/Year Study Purpose Sample/Setting Protocol Variables Findings
Baird et al To examine the Retrospective, 2-group Multimodal program: LOS Lower length of stay
(2010) impact of a comparison design preoperative for intervention
(surgical fast-track education, early group vs usual care
study) intervention Sample: ambulation, early 30-d hospital (4.66 d compared
program return to diet, new readmission with 5.87 d for usual
Total n = 200
(education, early anesthetic, analgesic, care patients
ambulation, early Intervention n = 100 and surgical
diet, etc) on Usual care (retrospective techniques; and best Readmission rates
length of stay and chart review) n = 100 practice (use of drains, between the 2 groups
30-d hospital tubes, and urinary were not statistically
readmission in Setting: Midwestern US catheters significantly different
laparoscopic postoperatively)
colorectal surgery
Gustafsson To examine the Prospective cohort Multimodal Adherence to the Postoperative
et al28 (2011) impact of different design program: ERAS ERAS protocol symptoms declined
(published adherence levels protocol including: significantly for
online) to the enhanced Sample: thoracic epidural Incidence of patients on the ERAS
(surgical study) recovery after analgesia; postoperative symptoms protocol
Total: 953 and complications
surgery (ERAS) preoperative oral
protocol and the Treated 2002Y2004: carbohydrates until LOS The proportion of
effect of various n = 464 2 h prior to surgery, adverse postoperative
ERAS elements and avoidance of outcomes (30-d
on outcomes Treated 2005Y2007; preoperative oral morbidity, symptoms,
following major n = 489 bowel preparation; and readmissions) was
colorectal surgery Setting: Stockholm, perioperative fluid significantly reduced
Sweden overloading; early with increasing
oral diet (4 h after adherence to the ERAS
surgery); and EM protocol
(2 h out of bed on the
day of surgery and Median LOS reduced
then 6 h daily) from 7 to 6 d for all
patient groups (not
statistically significant);
proportion of patients
with LOS within the
clinical target for
resections (7 d)
increased significantly
from 35.4% to 46.8%
Lee et al29 To evaluate the RCT Multimodal Recovery time Recovery time was
(2011) efficacy of a intervention: early (tolerate diet; safe shorter in the
(surgical study) rehabilitation Sample: oral feeding, early ambulation, rehabilitation program
program after Total n = 100 ambulation, and analgesic-free, and group than in the usual
laparoscopic regular laxative afebrile and free of care group (median
colon surgery Intervention: major complications) time 4 vs 6 d,
n = 46 respectively; P = .0001)

Usual care: Secondary outcomes: No difference in

postoperative LOS,
n = 54 LOS complication rates
Setting: Korea Complications, quality between groups
of life Quality of life and
pain were similar in
both groups
There were no
readmissions or

Clinical Nurse Specialist A 91

Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Feature Article

who cared for patients with CAP were randomly assigned ity protocol on patients who underwent above-the-knee
to provide the early mobilization intervention or usual or below-the-knee amputations.2 This study was con-
care. After the random assignment of units and careful re- ducted in a medical-surgical vascular unit at a large aca-
view of the exclusion criteria (hospitalization within the demic community hospital. The protocol was specifically
prior 2 weeks, diagnosis with large-volume aspiration designed to encourage and promote early and progressive
pneumonia, admission or transfer to an intensive care unit mobilization of postamputation patients. The researchers
or assignment to a nonstudy hospital unit), 458 patients examined the impact of the mobility protocol on the func-
were deemed eligible and enrolled in the study. Of the tional mobility and the length of stay of these participants.
458 participants, 227 were assigned to the early mobiliza- Functional mobility was defined by how much physical
tion intervention group, and 231 patients were assigned to assistance a participant needed to perform the following
usual care. According to the study protocol, early mobili- actions: supine to sit and sit to supine, stand pivot, sliding
zation was defined as movement out of bed with change board transfer, sit to stand and stand to sit, and finally dis-
from horizontal to upright position for at least 20 minutes tance ambulated in feet. Researchers found that the proto-
during the first 24 hours of the hospitalization with pro- col increased the functional mobility of the participants,
gressive mobilization on each subsequent day during but it did not impact the length of stay. Overall, study find-
hospitalization. These researchers found that the partici- ings indicate that early ambulation may positively impact
pants in the early mobilization group had significantly functional mobility of patients who underwent lower-
shorter length of stay (fewer inpatient days) compared limb amputations. More research is needed to understand
with the usual care group (Table). Importantly, patients if it reduces hospital length of stay in these patients.
in these 2 groups (early mobilization and usual care) did
not differ demographically (age and gender) or in relation Multimodal Rehabilitation Program Can Contribute
to their disease severity and treatment, supporting the hy- to Positive Outcomes for Patients Recovering From
pothesis that an early mobilization protocol resulted in Surgical Procedures
decreased length of stay for patients with CAP. Based Four studies examined the impact of multimodal interven-
on this large randomized controlled trial, an early mobili- tions on outcomes after surgery including laparoscopic
zation protocol can reduce clinical symptoms of CAP (as sigmoidectomy, laparoscopic colorectal or colon surgery,
seen by a faster recovery time Y a shorter length of stay) and major colon surgery. In 2004, researchers from Berlin,
and in effect also maintain functional well-being (as no Germany, conducted a study to evaluate the effects of a
hospital-associated complications were noted). However, multimodal rehabilitation program on patients who under-
further research is needed to replicate these findings. went an elective laparoscopic sigmoidectomy (Table).
In the multimodal or fast-task rehabilitation program,
Mobility Protocol (Based on Early Ambulation)
patients were consistently encouraged to perform early
Decreased the Hospital Length of Stay of Older Adults
ambulation (beginning from the day of surgery until the
Researchers in Rhode Island conducted a study to evaluate
day of discharge) in combination with epidural analgesia
the effect of a nurse-driven mobility protocol (based on early
and early oral feeding. Two different surgical units in a
ambulation) on a convenience sample of hospitalized adults
60 years or older.26 Two nursing units were selected for this Berlin hospital were selected to provide either early am-
study, and both were equal in size, cared for similar patient bulation or standard (usual care) treatment. Patients in
populations, and were characterized by similar nursing the early ambulation unit demonstrated significant clinical
staff composition. The nursing unit that implemented the improvement and were discharged earlier compared with
mobility protocol found that participants either maintained patients who received standard (usual care) treatment.
or improved their functional status from admission to dis- Similar results were noted by Lee and colleagues,29 who
charge. Furthermore, these participants had a reduced found that recovery time was shorter for those receiving
length of stay compared with the control nursing unit that a rehabilitation program that included early ambulation
did not implement the mobility protocol. Therefore, adop- in laparoscopic colon surgery. Baird et al27 also noted
tion of the nurse-driven mobility protocol (based on early lower length of stay for patients in a rehabilitation pro-
mobilization) led to the decreased length of stay in hospital- gram who were recovering from laparoscopic colorectal
ized elderly patients and maintained or improved their func- surgery. In addition, Gustafsson et al28 noted that par-
tional status from admission to discharge. ticipants who had greater adherence to the multimodal
rehabilitation program had fewer postoperative symp-
Use of a Mobility Protocol Improved the toms and complications than those who did not. Although
Functional Mobility of Patients Who Underwent early ambulation was not the only intervention provided
Lower-Limb Amputations in these studies, the results indicate that it may be an impor-
In 2008, researchers in eastern Pennsylvania conducted tant component to include within a multimodal reha-
an observational study to examine the effect of a mobil- bilitation program.

92 March/April 2012

Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Effects of Standardized Early Mobilization Protocols Including the basic elements of an early mobilization
In review of all studies, it was clear that those protocols protocol helped to control clinical symptoms in DVT pa-
that utilized a more standardized and structured format tients, laparoscopic sigmoidectomy patients, and patients
obtained the most significant results. The standardized recovering from colorectal surgery.22,24,25,28 In addition,
format was brought in by implementing a progressive we noted that an early mobilization protocol alone or in
series of specific mobility interventions (as defined by combination with other rehabilitative strategies can reduce
the hospital unit/organization/researcher) to help the length of stay and prevent complications known to be as-
patient attain and/or maintain his/her baseline mobility sociated with functional decline.
status. These specific mobility interventions began within Interestingly, the greatest and most direct impact on
24 hours of admission and were sustained throughout functional status occurred through standardized early mo-
the inpatient stay.2,23,26 These studies demonstrated that bilization protocols. These protocols include a series of
a more standardized early mobilization protocol can sig- specific (as defined by the hospital unit/organization/
nificantly improve the functional status of hospitalized researcher) mobility interventions implemented in a pro-
older adults and reduce the length of stay for patients gressive manner (throughout the inpatient stay) to help
with CAP and patients who underwent lower-limb ampu- promote or sustain the patients baseline mobility status.2,26
tations.2,26 In the case of surgical patients (laparoscopic Nurses will play a primary role in implementing these stan-
sigmoidectomy, laparoscopic colorectal or colon surgery, dardized early mobilization protocols as they directly ad-
and major colon surgery), only the basic tenets of an early dress the functional status (a nursing-sensitive outcome)
mobilization protocol were included in the structure of of the medical-surgical inpatient population.
a larger rehabilitation program24,27Y29 Patients who were Clinical nurse specialists will serve as the experts in
included in these rehabilitation programs experienced re- leading project teams to implement these types of stan-
duced length of stay, faster recovery time, and reduced dardized protocols. Clinical nurse specialists are in a
postoperative symptoms. prime position to collaborate with the bedside nurses,
as well as other healthcare team members (such as phys-
ical therapists, occupational therapists, and physicians),
to sustain an ongoing program of early mobilization of
Findings in this review must be taken in consideration of
medical-surgical inpatients. In addition, CNSs can be a
the limitations of the studies presented. One major limi-
primary resource to explore the impact of early mobiliza-
tation of this work is that researchers defined and imple-
tion on other outcomes for this population. For example,
mented early mobilization protocol in a slightly different
research to explore how early mobilization may promote
manner in each of the studies reviewed. Some researchers22
functional status (from admission to discharge) and sub-
defined and implemented early mobilization protocol as
sequently prevent hospital-acquired conditions such as
specific walking exercises; some2,23,26 included a stan-
falls and pressure ulcers within the medical-surgical inpa-
dardized form of a series of progressive mobility interven-
tient population is warranted. Measuring and document-
tions, and finally others24,27Y29 included early mobilization
ing the impact of early mobilization programs on falls
as a part of a larger rehabilitation program with other in-
and pressure ulcers would be an important contribution
terventions. Although the overall definition of early mobi-
to establishing best practices for caring for the hospitalized
lization was similar in all these studies, the implementation
medical-surgical patients.
method could impact the clinical outcomes noted in each
of these patient populations. Overall, more work is needed
that consistently defines early mobilization across studies,
In summary, prolonged immobility can be detrimental to
establishes the optimal dose of early mobilization, and
the health of all hospitalized patients. Early mobilization
determines its impact on clinical outcomes for various
is one nursing-amenable intervention that has previously
medical-surgical inpatient populations.
shown to provide positive outcomes for critical care, car-
diovascular, neurological (stroke patients), and orthopedic
IMPLICATIONS FOR CNS PRACTICE patient populations. This review including synthesis of the
Maintaining functional well-being, management of symp- literature, to our knowledge, is the first to explore the impact
toms associated with an acute clinical condition and of an early mobilization protocol in the medical-surgical in-
preventing hospital-associated complications are all nursing- patient population.
sensitive outcomes. An early mobilization protocol may The results of this review indicate that early mobilization
address each one of these nursing-sensitive outcomes. leads to positive outcomes for patients with a variety of
The findings of this empirical literature review suggest that medical diagnoses and surgical conditions. We found that
an early mobilization protocol can maintain and/or im- patients with DVT, older medical patients, and patients
prove functional status from admission to discharge.2,6Y8,26 with lower-limb amputations demonstrated improved

Clinical Nurse Specialist A 93

Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Feature Article

physical functioning (greater functional mobility), less pain, 14. Craig LE, Bernhadt J, Langhorne P, Wu O. Early mobilization after
enhanced well-being, and/or lower length of hospital stay. stroke: an example of an individual patient data meta-analysis of
a complex intervention. Stroke. 2010;41:2632Y2636.
Thus, this review supports the need to incorporate early 15. Botsuzan B, Gunes Y, Yildiz A, Bulut M, Saglam M, Kargin R.
ambulation as a nurse-driven intervention for medical- Early ambulation after diagnostic catheterization. Angiology.
surgical inpatients. Clinical nurse specialists will serve 2007;58(6):743Y746.
as the primary advocates to implement and sustain such 16. Macchi C, Fattirolli F, Lova R, Conti A, Luisi M, Intini R. Early
and late rehabilitation and physical training in elderly patients
a nursing-amenable intervention for the entire medical- after cardiac surgery. Am J Phys Med Rehabil. 2007;86(10):
surgical inpatient population. 826Y834.
17. Chair S, Thompson D, Li S. The effect of ambulation after car-
References diac catheterization on patient outcomes. J Clin Nurs. 2007;16:
1. Kleinpell RM, Fletcher K, Jennings BM. Reducing functional 212Y214.
decline in hospitalized elderly. In: Hughes RG, ed. Patient 18. Mumford E. Early active motion in joint pain and stiffness. Clin
Safety and Quality: An Evidence-Based Handbook for Nurses. Orthop Relat Res. 2008;466:113Y116.
Rockville, MD: Agency for Healthcare Research and Quality 19. OSullivan M, Savage E. Nursing contributions to mobilizing
(AHRQ); 2008:251Y265. older adults following total hip replacement in Ireland. J Orthop
2. Marzen-Groller DK, Tremblay MS, Kaszuba J, et al. Testing the Nurs. 2008;12(3):181Y186.
effectiveness of the Amputee Mobility Protocol: a pilot study. 20. Majewski M, Schaeren S, Kohlhaas U, Ochsner P. Postoperative
J Vasc Nurs. 2008;26(3):74Y81. rehabilitation after percutaneous Achilles tendon repair: early
3. Bahman SR, Ebel EB, Corso SP, Molinari MN, Koepsell DK. functional therapy versus cast immobilization. Disabil Rehabil.
The acute medical care costs of fall-related injuries among 2008;30(20):1726Y1732.
U.S. older adults. Int J Care Inj. 2005;36(11):1316Y1322. 21. National Quality Measures Clearinghouse. Intensive care: per-
4. Armstrong DG, Ayella EA, Capitulo KL, Fowler E, Krasner DL, centage of adult patients having had an intensive care unit stay
Smith AP. New opportunities to improve pressure ulcer preven- whose hospital outcome is death. 2010. http://www.quality
tion and treatment: implications of the CMS inpatient hospital Ac-
care present on admission indicators/hospital-acquired conditions cessed February 5, 2010.
policy: a consensus paper from the International Expert Wound 22. Partsch H, Blattler W. Compression and walking versus bed
Care Advisory Panel. Adv Skin Wound Care. 2008;21(10):469Y478. rest in the treatment of proximal deep venous thrombosis with
5. Tucker D, Molsberger CS, Clark A. Walking for Wellness: a col- low molecular weight heparin. J Vasc Surg. 2000;32:861Y869.
laborative program to maintain mobility in hospitalized older 23. Mundy ML, Leet LT, Darst K, Schnitzler AM, Dunagan C. Early
adults. Geriatr Nurs. 2004;25:242Y245. mobilization of patients hospitalized with community acquired
6. King DB. Functional decline in hospitalized elders. Medsurg pneumonia. Chest. 2003;124:883Y889.
Nurs. 2006;15(5):265Y271. 24. Raue W, Hasse O, Junghans T, Scharfenberg M, Muller MJ,
7. Callen LB, Mahoney EJ, Grieves BC, Wells JT, Enloe M. Fre- Schwenk W. Fast track multimodal rehabilitation program im-
quency of hallway ambulation by hospitalized older adults on proves outcome after laparoscopic sigmoidectomy. Surg Endosc.
medical units of an academic hospital. Geriatr Nurs. 2004;25(4): 2004;18:1463Y1468.
212Y217. 25. Partsch H, Kaulich M, Mayer W. Immediate mobilization in
8. Graf C. Functional decline in hospitalized older adults. Am J acute vein thrombosis reduces post-thrombotic syndrome. Int
Nurs. 2006;106:58Y68. Angiol. 2004;23(3):206Y213.
9. Bailey P, Thomsen G, Spuhler V, Blair R, Jewkes J, Bezdjian L. 26. Padula AC, Baumhover L. Impact of a nurse-driven mobility
Early activity is feasible in respiratory failure patients. Crit Care protocol on functional decline in hospitalized older adults. J
Med. 2007;35:139Y145. Nurs Care Qual. 2009;24(4):325Y331.
10. Morris P, Herridge M. Early intensive care unit mobility: future 27. Baird G, Maxson P, Wrobleski D, Luna BS. Fast-track colorectal
directions. Crit Care Clin. 2007;23:97Y110. surgery program reduces hospital length of stay. Clin Nurse
11. Needham D, Chandolu S, Zanni J. Interruption of sedation for Spec. 2010;24(4);202Y208.
early rehabilitation improves outcomes in ventilated, critically 28. Gustafsson OU, Hausel J, Thorell A, Ljungqvist O, Soop M,
ill adults. Aust J Physiother. 2009;55(3):210. Nygren J. Adherence to the enhanced recovery after surgery
12. Cumming BT, Collier J, Thrift GA, Bernhardt J. The effect of protocol and outcomes after colorectal cancer surgery. Arch
very early mobilization after stroke on psychological well- Surg. 2011;146(5):571Y577.
being. J Rehabil Med. 2008;40:609Y614. 29. Lee T-G, Kang S-B, Kim D-W, Hong S, Heo SC, Park KJ. Com-
13. Cuming BT, Thrift AG, Collier JM, et al. Very early mobilization parison of early mobilization and diet rehabilitation program
after stroke fast-tracks return to walking: further results from with conventional care after laparoscopic colon surgery: a pro-
phase II AVERT randomized controlled trial. Stroke. 2011;42: spective randomized controlled trial. Dis Colon Rectum. 2011;
153Y158. 54:21Y28.

94 March/April 2012

Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.