See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/8489481

Admission and discharge mobility of frail hospitalized older adults

Article  in  Medsurg nursing: official journal of the Academy of Medical-Surgical Nurses · July 2004
Source: PubMed

CITATIONS READS

25 490

5 authors, including:

Bonnie L Callen Jane E Mahoney

University of Tennessee University of Wisconsin–Madison
41 PUBLICATIONS   359 CITATIONS    44 PUBLICATIONS   1,711 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Teaching/Learning Strategies for the Essentials of Baccalaureate Nursing Education for Entry-Level Community/Public Health Nursing View project

All content following this page was uploaded by Bonnie L Callen on 22 June 2016.

The user has requested enhancement of the downloaded file.

 MEDSURG NURSING
CE Objectives and Evaluation Form appear on page 164.

Admission and Discharge

Mobility of Frail Hospitalized
Older Adults
Bonnie L. Callen Thelma J. Wells Susan Hughes
Jane E. Mahoney Myra Enloe

Functional decline during hos-

pitaiization is an important clini-
cal problem with potential long-
lasting undesirable outcomes in
frail elders. However, little is
known about the change in mobil-
ity during hospitaiization and the
association with discharge .status.
A Mobility Classification Tool has
been developed that categorizes
progression of patients' in-hospital
mobility using a 5-point scale. The
validity and clinical usefulness of
this tool was evaluated in a sam-
ple of 60 frail older adults hospi-
talized for medical illness. The
tool allows nurses to assess, quan-
tify, and communicate mobility
levels and changes in mobility
more accurately.
I mmobility is a common occur-
rence among hospitalized elders
and may contribute to multiple,
long-lasting adverse physiologic and
functional outcomes. Functional
decline during hospitaiization is an
important clinical problem with
potential long-lasting undesirable
outcomes, but little is known about
the change in mobility during hos-
pitaiization and the association
with the elder's discharge status.
Furthermore, changes in mobility
are difficult to quantify and com-
Myra Enloe, MS, RN, is Patient Safety Officer, University of Wisconsin Hospital,
Madison. WI.
Sus£ui Hnghes, MS, RN, is a Senior Research Specialist, University of Wisconsin-
Madison, School of Nursing, Madison, WI.
municate due to limited mobility
language in nursing practice. When
mobility is conceptualized as a
continuum progressing from bed-
bound to independent walking, a
single scale could contribute to
more precise documentation of
changes in mobility. Thus, changes
in mobility and outcomes of these
changes could be monitored and
evaluated.
Background
Bed rest in young healthy

Bonnie L Callen, PhD, RN, is an
Assistant Professor, University of
Tennessee College of Nursing, Knoxville,
TN.
Jane E. Mahoney, MD, is an Assistant
Professor of Geriatrics, University of
Wisconsin-Madison, WI.
Thelma J. Wells, PhD, RN, FAAN, is
Professor Emerita of Nursing, University
of Wisconsin-Madison, WI.
Funding: This study was funded by the University of Wisconsin Graduate School and
the University of Wisconsin Hospitals and Clinics Department of Nursing.
Publisher's Note: Publication of this article was supported by a grant provided by
Nurse Competence in Aging, a 5-year initiative funded by The Atlantic Philanthropies
(USA) Inc., awarded to the American Nurses Association (ANA) through the American
Nurses Foundation (ANP"), and representing a strategic alliance between ANA, the
American Nurses Credentiaiing Center (ANCC), and the John A. Hartford Foundation
institute for Geriatric Nursing, New York University, The Steinhardt School of
Education, Division of Nursing.
For more information, contact the John A. Hartford Foundation Institute for Geriatric
Nursing, New York University, The Steinhardt School of Education, Division of Nursing,
246 Greene Street, 5th Floor, New York. NY 10003, or call (212) 998-9018, or email hart-
ford.ign@nyu.edu or access the Web site at www.hartfordign.org

156 MEDSURG Nursing—June 2004—Vol 13/No. 3


adults results in declines in mus-
cle mass and strength (Bloomfield,
1997; LeBlanc et al., 1992), slowed
gait speed (Dupui, Montoya,
Costes-Salon, Severac, & Guell,
1992), orthostatic incompetence
(Creditor, 1993), increased body
sway (Dupui et al., 1992), impaired
psychomotor coordination (Zubek,
Bayer. Mllstein, &Shephard, 1969),
and depression (Ishizaki et al.,
1994). Little is known about the
impact of bed rest during hospital-
ization in older adults, but it is
assumed that the negative effects
of bed rest on healthy young adults
are compounded for elders.
Hospitalization for acute illness is a
critical event for older adults,
bringing witb it a high likelihood of
short-term or long-term loss of
function. Many hospitalized older
adults spend a great deal of their
time in bed. Undesirable out-
comes associated with hospital-
ization include loss of walking
independence, increased risk of
nursing home placement (Sager et
al., 1996a), and increased risk of
falls, both during and after hospi-
taiization (Mahoney et ai., 2000).
These adverse consequences are
related to multiple factors, includ-
ing illness, new medications, and
iatrogenic complications, but it is
likely that bed rest during hospi-
talization contributes substantial-
ly to deconditioning, falls, and
nursing home placement.
Available data suggest that
provision of mobility to hospital-
ized patients is markedly inade-
quate. In a 1991 study of older
adult medical-surgical patients at
five hospitals, Lazarus and col-
leagues found that 24% of patients
had no ambulation noted in nurs-
ing records during the first 7 hos-
pital days. On 23% of their days in
the hospital, patients did not get
out of bed; according to chart
review, these elders did not ambu-
late at all on half of their hospital
days. Of patients who were chair
or bedbound for an entire week,
MEDSURG Nursing—June 2004—Vol. 13/No. 3
Admission and Discharge Mobility of Frail Hospitalized Older Adults
only 12% received physical thera-
py (Lazarus, Murphy, Coletta,
McQuade, & Culpepper, 1991).
About one-third of hospital-
ized older adults experience a
decline in function as measured
by activities of daily living (ADLs)
(McVey, Becker, Saltz, Feussner, &
Cohen, 1989; Sager et al., 1996b).
During hospitalization, older
adults are at high risk for loss of
walking, toileting, and transferring
skills. Studies have shown that
15% of older adults hospitalized
for medical illness become newly
dependent on others to walk
across a room (Mahoney, Sager, &
Jalaluddin, 1998; McVey et al.,
1989). Decline in transferring and
toileting occurs with similar fre-
quency (Hirsch, Sommers, Oisen,
Mullen, & Winograd, 1990; McVey
et al., 1989; Sager et al., 1996b).
Decline in ADL function during
hospitalization is associated with
multiple adverse outcomes,
including discharge to a nursing
home and persistent functional
decline 3 months after discharge
(Landefeld, Palmer, Kresevic,
Fortinsky, & Kowal, 1995; Rudberg,
Sager, & Zbang, 1996; Sager et al.,
1996a). Specifically, loss of walking
independence is strongly associat-
ed with continued walking depen-
dence 3 months following dis-
charge from acute care (Mahoney
et al., 1998). An additional nega-
tive consequence of functional
decline during hospitalization is
the increased risk for falls follow-
ing hospital discharge (Mahoney
et al., 2000; Mahoney, Sager,
Dunham, & Johnson, 1994).
It is projected that by the year
2030, 1 in 5 people will be 65 years
of age or older. Further, in 2000,
Americans 65 years of age and
older had four times the number
of hospitalization days as did
those under the age of 65 (Federal
Interagency Forum on Aging-
Related Statistics, 2000). Given the
changing demographics of the
population and the potential
severity of adverse effects associ-
ated with immobility during hospi-
talization, it becomes critical that
tools be developed and tested to
measure mobility, and methods
tested to prevent immobility-relat-
ed consequences in the hospital
setting.
Purpose
The purpose of this study was
to evaluate the validity and clini-
cal usefulness of the Mobility
Classification Tool on admission
and at discharge for frail older
adults being cared for on an acute
care medical hospital unit.
Specific goals were to:
• Characterize the relationship of
admission mobility level to
patient characteristics at
admission.
• Describe the change in mobility
level during hospitalization.
• Examine the relationship of
admission and discharge mobil-
ity level to discharge location.
• Examine the relationship of
admission and discharge mobil-
ity level to discharge function
and length of hospital stay.
Methods
Institutional review board
(IRB) approval was obtained at
the study site, a major teaching
and tertiary care hospital in
Wisconsin. A prospective cohort
of patients aged 65 or older admit-
ted to a medical unit was screened
with the Hospital Admission Risk
Profile (HARP) from June through
August 2001. The HARP is a risk
assessment tool used on hospital
admission that predicts functional
decline and discharge to a nursing
home. This tool classifies patients
as low, intermediate, or high risk
for functional decline based on
three factors: age, cognition, and
pre-hospital independent activi-
ties of daily living (IADLs) (Sager
et al., 1996b). Inclusion criteria for
this study were: (a) age 65 and
older, (b) admitted from home,
157
 Admission and Discharge Mobility of Frail Hospitalized Older Adults

sems
Table 1.
Mobility Classification Tool

Check mobility Passive Active Assisted Independent

level for each Bedbound Transfer Transfer Walking Walking
shift and initial Level 1 Level 2 Level 3 Level 4 Level 5
Bedbound or Bed-to-chair Bed-to-chair with Assisted (hands Walks without
confined to bed activity with NO partial to full on); full weight assistance
on medical/ weight bearing weight bearing bearing and
nursing orders ambutation
A Patient depen- Transferred to Two-person Walk; with two Walk independent
Maximum dent: Staff pro- cardiac chair assist; stand and assist in room only
restriction or vides all turning, pivot to chair,
dependence positioning, and wheelchair, or
ROM commode

B Patient partici- Mechanical or One-person Walk; with Walk out of

pates with staff three-person lift assist; stand and one assist room; < 1 hall
assist in turning, to chair, wheel- pivot to chair, length
positioning, and chair, or com- wheelchair, or
ROM mode commode
C Patient is Transfer to chair, One-person Walk; with Walk out of
Least restricted/ independent wheelchair, or standby assist to standby assist room; > 1 hall
Least depen- in bed commode with chair, wheelchair, length,
dence two-person assist or commode

Terms:
• Independence: Patient able to perform alone
• Assistance: Nurse touching patient and providing effort for mobility

How to use this form:

• Determine Level (1 thru 5)
• Determine level of dependence (A, B, C)

and (c) at intermediate or high
risk according to the HARP.
Exclusion criteria were (a) short
stay (length of hospital stay 48
hours or less), and (b) terminally
ill (life expectancy of less than 30
days as determined by the admit-
ting nurse).
Measures
Mobility Classification Tool. In
1997, a collaborative interdiscipli-
nary research team at the
University of Wisconsin Hospital
and Clinics began an examination
of the mobility language used in
acute care. A chart review was
conducted for the 289 subjects
who had entered a previous study
to gather hospital data on mobili-
ty. Limited chart data on mobility
were found. Also noted was the
lack of clarity relating to mobility
terms (for example, up ad lib, may
ambulate, chair). How did nurses
interpret these terms? An explo-
ration of the literature found only
limited discussion of mobility as a
concept in nursing (Ouellet &
Rush, 1992). Limited descriptive
patient mobility terminology in
nursing could be found. For exam-
ple, basic activities of daily living
described patient mobility in two
categories: walking and transfers.
Through a series of research
team discussions, and with input
from expert staff nurses, mobility
was conceptualized as a continu-
um from completely dependent or
bedbound to completely indepen-
dent. A five-level Mobility
Classification Tool was developed
(see Table 1). Five senior nurses
assigned to leadership clinical roles
on the unit, each with greater than
10 years of experience in medical-
surgical nursing, provided feed-
back on content and language.
The tool was implemented on the
unit. The nurses provided written
feedback as they used the tool.
Feedback contributed to modifica-
tions. This tool classifies patient
mobility as: (1) bedbound. (2)
bed-to-chair with no weight bearing,
(3) bed-to-chair with partial weight
bearing. (4) assisted (hands on) full
weight bearing, and (5) walks with-
out assistance. Subcategories A to C

158 MEDSURG Nursing—June 2004—Vol. 13/No. 3


Table 2.
Participant Measures
Abbreviated Mini-Mental State Examination
{RangeO-21)
Activities of Daily Living
(Range 0 - 6 )
Instrumental Activities of Daily Living
(Range 0 - 7 )
HARP Category
Intermediate
High
Although HARP scores were available for 60 subjects, subscores were not
recorded for all subjects.
under each level described the
degree of assistance or indepen-
dence for that level. Originally con-
ceptualized as a potential 15-point
scale, in practice, the subcategories
seemed to reflect nurse manage-
ment of patient mobility. Thus,
while the potential for further tool
refinement exists, the tool func-
tioned as a I to 5 continuum for this
study which focused on validity.
Inter-rater reliability was
assessed for 14 pairs of nursing
staff raters. Agreement on catego-
ry and subcategory was S6%. In
the two cases where raters did not
agree, the mobility aide, a special-
ly trained nursing assistant
assigned solely to assist patients
in ambulating, rated mobility level
higher than other nursing staff
(one RN, one other nursing assis-
tant) caring for the patient. Scores
were validated by the trained
mobility aides during actual daily
mobilization.
Activities of Daily Living. Katz
Activities of Daily Living (ADLs)
were assessed on admission and
discharge for six items (bathing,
dressing, toileting, eating, trans-
ferring, and walking across a small
room) (Katz, Downs, Cash, &
(irotz, 1970) (see Table 2). This
scale measured each ADL on three
MEDSUBG Nursing—June 2004—Vol 13/No. 3
Admission and Discharge Mobility of Frail Hospitalized Older Adults
n % Mean SD
54*
14.26 6.06
53* 2.28 2.15
56* 2.38 2.05
28 46.7
32 53.3
levels (no help needed, help need-
ed, or unable to do). Admission
ADLs are strongly linked to dis-
charge and post-discharge ADL
function (Hirsch et al., 1990: Sager
et al., 1996a). The summation
score measures the number of
activities for which no help was
needed. Scores range from 0 to 6,
with higher scores indicating
greater independence. The scale
demonstrates excellent reliability,
validity, and predictive validity,
and has shown sensitivity to
change for hospital and post-hos-
pital use (Inouye et al., 1993; Katz
etal., 1970; Wu etal., 2000).
Abbreviated Mini-Mental State
Examination (MMSE). Cognition
was measured using the abbreviat-
ed MMSE, a 21-item version of the
MMSE. Scores range from 0 to 21,
with higher scores indicating
greater cognitive function (see
Table 2). A score of 14 or less
implies cognitive dysfunction
(Folstein, Folstein, & McHugh,
1975; Sager et al., 1996b). The
abbreviated MMSE omits language
items because of the difficulty of
collecting these in the hospital.
Correlation between the 21-item
MMSE and the standard 30-item
MMSE has been reported as r^().9O,
(p<0.001) (Sager et al., 1996b).
Instrumental Activities of Daily
Living (lADLs). On hospital admis-
sion, the admitting nurse asked
about lADLs 2 weeks prior to
admission. lADLs assess the levels
at which an older adult can per-
form seven tasks required for
independent living and are more
sophisticated than ADLs. These
functions include using the tele-
phone, getting to places beyond
walking distance, shopping for
groceries, preparing meals, doing
housework, taking medications,
and managing finances. Scores
range from 0 to 7, with higher
scores indicating greater indepen-
dence (Lawton & Brody, 1969)
(see Table 2). Items requiring no
assistance were scored 1, while
items requiring some assistance
or which the person is unable to
do receive a score of 0.
The Hospital Admission Risk
Profile (HARP) categorizes older
adults into risk categories based
on age, cognition (abbreviated
MMSE) at time of hospital admis-
sion, and IADLs 2 weeks prior to
hospital admission. HARP catego-
rizes patients into three cate-
gories: high risk, intermediate
risk, or low risk. Scores range from
0 to 5, with higher scores indicat-
ing greater risk (see Table 2). This
tool has been used to identify
patients at risk for functional
decline following hospitalization
(Sager et al., 1996a).
Procedure
On admission, data were col-
lected by staff nurses and special-
ly trained nursing assistants.
Mobility level and ADLs were
assessed daily by nursing staff.
Nursing assistants received a full
day of training from members of
the research team on mobility
classification and mobility levels,
as well as appropriate ambulation
and transfer techniques. Super-
vised each day by the charge
nurse and monitored by the
research staff, the aides would
159
 Admission and Discharge Mobility of Frail Hospitalized Older Adults
determine the mobility level from
the previous day and then check
with the nurse for any changes.
They would then see the patients,
get them up, and record the mobil-
ity levels for that day. ADLs were
collected and recorded as part of
routine unit care.
Sample and .setting. The setting
for this study was one medical unit
with 28 beds at a Midwestern uni-
versity-based health care center.
From June to August 2001, 123
patients ages 65 and older admitted
to this unit from home were evalu-
ated. Of these, 13 were short stay
(hospital stay of less than 48
hours), and 4 were terminally ill
(life expectancy less than 30
days). Of the remaining 103, 60
were at intermediate or high risk
according to HARP and composed
the sample of this study. Subject
characteristics on admission are
reported in Table 3. Results of the
four specific purposes of this
study will next be summarized.
The study was approved by
the IRB of the University of
Wisconsin Hospital and Clinics.
Consent was not considered nec-
essary because all mobility and
ambulation was part of a unit-wide
improvement program.
Results
Descriptive statistics were
used to summarize the data. Chi-
square analysis was used to exam-
ine differences on admission in
gender. HARP category, and dis-
charge location among the mobili-
ty levels. One-way analysis of vari-
ance (ANOVA) was used to look at
differences in age, ADLs, IADLs,
abbreviated MMSE, and length of
stay among mobility levels. A
paired samples t-test was used to
examine the changes in mobility
levels between admission and dis-
charge. Pearson r was used to
examine correlations between
mobility levels and discharge
ADLs. Because ADLs and mobility
levels were collected daily during
160
Table 3.
Participant Characteristics {N=60)
Age
Female
Caucasian
Primary Admission Diagnoses
Pulmonary
GI
Circulatory
Musculoskeletal
Other
hospitalization, the last ADL and
mobility level collected (either on
the day of discharge or the day
prior to discharge) were defined
as discharge ADLs and mobility
level.
Relationship of mobility level
to patient characteristics on hospi-
tat admission (.see Table 4). At hos-
pital admission, 15% of the
patients were bedbound (Level 1),
20% were unable to bear weight
(Level 2), 12% were able to bear
partial weight (Level 3), 37% were
able to walk with assistance (Level
4), and 8% were able to walk inde-
pendently (Level 5). Higher mobil-
ity level at admission was associ-
ated with a higher score on ADLs
(p^O.OOO), as well as a higher cog-
nitive status as measured by the
abbreviated MMSE (p=0.025). On
admission, the HARP, which
screens for age, cognition, and
pre-hospital IADLs, indicated that
those who were bedbound
(Mobility Level 1) were most likely
to be at high risk (78%), while
those able to ambulate indepen-
dently (Mobility Level 5) were
least likely (20%) to be at high risk
for functional decline. The mean
admission mobility level for inter-
mediate-risk patients according to
the HARP screening was 3.4; the
mean for high-risk HARP patients
n % Mean SD
80.48 7.80
38 63
59 98
12 20
11 18
10 17
6 10
21 35
was 2.7 (p=0.055), indicating a
trend for lower mobility to be
associated with higher risk for
functional decline during hospital-
ization. There were no significant
gender differences between mobil-
ity levels at admission.
Change in mobility level during
hospitalization. The percentage of
patients at each mobility level
demonstrates an overall improve-
ment in mobility. The number of
bedbound patients was reduced
10% (15% on admission to 5% on
discharge). Correspondingly, the
percentage of independent patients
increased from 8.3% on admission
to 13.3% on discharge. See Figure 1
for detail on all mobility cate-
gories at hospital admission and
discharge; the percentage distrib-
ution is similar comparing admis-
sion and discharge mobility. The
improvement from admission
(mean mobility level 3.04, SD 1.29)
to discharge (mean mobility level
3.45, SD 1.10) was statistically sig-
nificant (t-2.91; /?=005). Little
recovery of independence in walk-
ing occurred among those who
were less than independent at
admission. Of the 51 subjects who
were less than independent at
admission, only 4 (8%) achieved
independence in walking in an
average length of stay of 8 days.
MEDSURG Nursing—June 2004—Vol. 13/No. 3
 Admission and Discharge Mobility of Frail Hospitalized Older Aduits

Table 4.
Relationship of Mobility Level to Patient Characteristics on Hospital Admission

Passive Active Assisted Independent

Bedbound Transfer Transfer Walking Walking
Level 1 Level 2 ' Level 3 Level 4 Level 5
n 9 12 7 22 5
Age (mean) 82.67 77.89 81.00 81.63 79.00 0.516
Gender
Female 66.70 58.30 85.70 63.60 40.00 0.581
Male 33.30 41.70 U.30 36.40 60.00 0.581
ADL (mean) 1.13 1.36 1.71 3.00 6.00 0.000
lADL {mean) 2.00 2.00 1.78 2.21 4.14 0.307
MMSE (mean) 11.63 9.60 17.00 15.57 17.00 0.025
HARP
High {%) 77.80 58.30 57.10 50.00 20.00 0.299

Figure 1. Relationship of admission and

Mobility Level on Admission and Discharge discharge mobility level to dis-
charge function and length of stay
50 in hospital. On both admission and
*-< 40 discharge, mobility level was
C strongly correlated with discharge
0) 30 ADL scores. Admission mobility
u level was strongly correlated with
0) discharge ADLs (r-0.66, p=0.000).
Q. 20
10 Discharge mobility level was simi-
larly correlated with discharge
0
ADLs (r=0.73, p-0.000). In other
Bedbound Passive Active Assisted Independent words, a strong relationship exists
Transfer Transfer Walking Walking between a patient's mobility level
and his or her functional level
Mobility Level measured by ADLs. Differences in
length of stay between mobility
I Admission • Discharge levels was not statistically signifi-
cant, F (4, 50) ^ 1.762, p-0.151.

Relationship of admission and
discharge mobility level to discharge
location (see Figure 2). Of those
classified at discharge by the
Mobility Classification Tool as Level
1 (bedbound). 100% were newly
placed to a nursing home. For those
at Level 2 at discharge (bed-to-chair
with no weight bearing), 89% went
to a nursing home, while 91% of
those at Level 3 (bed-to-chair with
partial weight bearing). 63% of
those at Level 4 (assisted full
weight bearing), and only 13% of
those who could walk without
assistance went to a nursing home
(X^-17.31, p=0.002). Thus, mobility
level was strongly associated with
discharge location. Mobility level at
admission was also significantly
associated with discharge to a nurs-
ing home (y;= 2..S3, p=0.014).
Discussion
The validity and clinical use-
fulness of a Mobility Classification
Tool was evaluated in 60 frail older
adults hospitalized for medicai ill-
ness. This tool demonstrated
good inter-rater reliability and
good construct validity as illus-
trated by the association with
admission ADLs and the abbrevi-
ated MMSE. Additionally, both
admission and discharge mobility

MEDSURG Nursing—June 2004—Vol. 13/No. 3 161

 Admission and Discharge Mobility of Frail Hospitalized Older Adults
levels were associated with dis-
charge location. It is important to
note that all of these patients lived
at home prior to admission.
When change in mobility for
patients at intermediate and high
risk (HARP) was analyzed, marked
mobility impairment at admission
and little change in mobility dur-
ing hospitalization were noted.
According to the Mobility Classi-
fication Tool, patients only im-
proved one-half a level on average,
indicating limited recovery of
independent walking during hos-
pitalization. Very few patients pro-
gressed to independent walking.
Limited recovery of independent
walking was strongly associated
with new placement to a nursing
home at hospital discharge. These
data suggest that the ability to
walk independently may be a criti-
cal factor in discharge disposition. frame of nursing action. In con-
They also indicate that in this
group, dependence in walking at
the time of admission is a sentinel
occurrence demonstrating a high
risk for nursing home placement
among frail older adults. A third
implication of these data is that
greater attention is needed to
patients' independence in walking
during hospitalization. Further
study is needed to determine if
this would decrease the need for
discharge to a nursing home.
The Nursing Outcomes
Classification (NOC) (Johnson,
Mass, & Moorhead, 2000). pub-
lished after the conceptualization
of this mobility classification tool,
uses two scales in the domain of
functional health to classify mobil- have been affected and perhaps
ity, one for those able to walk and
another for those using a wheel-
chair for mobility. Ambulation:
Walking, defined as the ability to study. A third limitation is that all
walk from place to place, uses a
five-point scale to classify walking medical unit. Patients with med-
from dependent to completely
independent. A second division of
mobility is Ambulation.' Wheelchair, other units.
defined as the ability to move from
place to place in a wheelchair
162
Figure 2.
Percentage of Subjects Newly Discharged to an Inpatient Facility by
Admission and Discharge Mobility Level
100
c 80
v 60
u
40
20
0
Bedbound Passive
Transfer
Mobility Level
[Admission • Discharge
(Johnson et al., 2000), While physi-
cal therapy had related terminokv
gy. it focused more narrowly and
did not meet either the breadth or
trast, the Mobility Tool encapsu-
lates classification mobility in one
scale reflecting a progression from
bedbound to independence in
ambulation. This scale reflects the
trajectory of mobility progression
for acutely ill patients in the hos-
pital setting.
Limitations of this study are
the lack of information on perfor-
mance of ADLs 2 weeks prior to
admission to assess function prior
to the illness that required hospi-
talization. Presence of a mobility
aide whose sole function was to
ambulate patients may have influ-
enced care. Ongoing research also
may have been a factor in the
usual care on this unit. Care may
improved by daily attention to
mobility; however, little progress
was shown in the subjects of this
patients in this study were on a
ical conditions may differ from
those admitted to surgical or
This Mobility Classification is
a useful tool, more precise than
Active Assisted Independent
Transfer Walking Walking
ADLs for assessing mobility. It
enables nursing staff to quantify
and communicate more accurate-
ly the mobility levels and changes
in mobility of elders hospitalized
in acute care. Because walking
during hospitalization may be key
to discharge placement, identify-
ing changes in mobility of even
half a level can direct nursing care
and the amount of assistance
needed by hospitalized frail
elders. The tool's precision may
make it highly useful for research,
but it does need further develop-
ment. This study was a first step in
the examination of this tool, but
additional testing is needed.
Results focused only on patients
at intermediate or high risk for
functional decline; future research
should also include those at low
risk for functional decline.
Consistent use of this tool will
allow important questions to be
answered. Can mobility be
improved in acute care? Will that
improvement increase the proba-
bility of the patient's discharge to a
home setting rather than to a nurs-
ing home? With increasing health
care dollars being spent on older
adults, future research should
focus on improving mobility during
hospitalization to maintain their
independence. •
MEDSURG Nursing—June 2004—Vol. 13/No. 3
References
Adnnission and Discharge Mobility of Frail Hospitalized Oider Adults
Bloomfield, S.A. (1997). Changes in musculoskeletal structure and
function with prolonged bed rest, t^edicine & Science in Sports &
Exercise. 29{2). 197-206.
Creditor, M.C, (1993)- Hazards of hospitalization of the elderly. Annals
of Internal t<Aedicine. 118(3), 219- 223,
Dupui, P.. Montoya, R.. Cosles-Salon, M.C. Severac. A., & Guell, A
(1992). Balance and gait analysis after 30 days - 6 degrees bed
rest: Influence of lower-body negative-pressure sessions. Aviation
Spaced Environmentalt^^edicine. 63(11), 1004-1010.
Federal Interagency Forum on Aging-Related Statistics. (2000). Older
Americans 2000: Key indicators of well-being. Retrieved February
4. 2004, from http://www.aoa.gov/agingstat
Folslein. M.F, Folstein, S.E., & McHugh. PR, (1975). "Mini-mental
state." A practical method for grading the cognitive state of patients
tor \Ue cWniaan. Journal of Psychiatric Research, 12(3), 189-198.
Hirsch. C.H., Sommers, L.. Olsen, A.. Mullen, L.. & Winograd. C.H.
(1990). The natural history of functional morbidity in hospitalized
older patients. Journal of the American Geriatrics Society. 35( 12),
1296-1303.
Inouye, S.K., Wagner, D.R.. Acampora. D., Horwitz. R.I., Cooney L.M.,
Jr, Hurst, L.D., et al. (1993). A predictive index for functional
decline in hospitalized elderly medical patients. Journal of General
Internal t[/ledicine. 8(^2), 645-652.
(shizaki. Y, Fukuoka, H., Katsura, T, Nishimura, Y., Kiriyama, M.,
Higurashi. M., et al. (1994). Psychological effects of bed rest in
young healthy subjects. Acta Physiologica Scandinavlc.
Supplementurn(6^6Q). 83-87.
Johnson, M., Mass, M., S Moorhead, S. (Eds.). (2000). Nursing out-
comes classification (NOCj (2nd ed,). St. Louis: Mosby, Inc.
Katz, S., Downs. TD., Cash. H.R., & Grotz. R,C. (1970). Progress in
development of the index of adi. Gerontologist. 10{^). 20-30.
Landefeld. C.S.. Palmer. R.M.. Kresevic, D,M.. Fortinsky R.H., & Kowai,
J. (1995), A randomized trial of care in a hospital medical unit
especially designed to improve the functional outcomes of acute-
ly ill older patients. New England Journal of Medicine. 332(20),
1338-1344.
Lawton, M.P, & Brody, E.M. (1969). Assessment of oider people: Self-
maintaining and instrumental activzities of daily living. Gerontologist,
9(3). 179-186,
Lazarus, B.A., Murphy. J,B., Coletta, E.M.. McQuade, W.H., &
Culpepper, L. (1991).The provision of physical activity to hospital-
ized elderly patients. ,4rc/7/ves of/nferna/Med/c/ne, ?5/(12),2452-
2456.
LeBlanc, A.D.. Schneider, VS., Evans, H,J., Pientok. C, Rowe, R.,
Spector, E., et al. (1992). Regional changes in muscle mass fol-
lowing 17 weeks of bed rest. Journal of Applied Physiology, 73(5),
2172-2178.
Mahoney, J., Sager, M.. Dunham, N.C, & Johnson, J. (1994). Risk of
falls after hospital discharge. Journal of the American Geriatrics
Society. 42(3). 269-274.
Mahoney, J-E,, Palfa, M., Johnson. J., Jalaluddin, M.. Gray, S,, Park, S,,
et al. (2000). Temporal association between hospitalization and
rate of falls after discharge. Archives of Internal Medicine. 160( 18),
2788-2795.
Mahoney, J.E.. Sager, M.A., & Jalaluddin, M. (1998). New walking
dependence associated with hospltaiization for acute illness:
Incidence and significance. Journal of Gerontology, 53A, M307-
M312.
McVey L.J., Becker, PM.. Saitz, C.C, Feussner, J,R,, & Cohen, H.J.
(1989). Effect of a geriatric consultation team on functional status
of elderly hospitalized patients. A randomized, controlled clinical
\r\a\. Annals of Internal Medicine. nO(1), 79-84,
Ouellet, L.L.. & Rush, K.L. (1992). A synthesis of selected literature on
mobility: A basis for studying impaired mobility. Nursing Diagnosis,
3(2). 72-80.
MEDSURG Nursing—June 2004—Vol. 13/No, 3
Rudberg, M.A., Sager, M.A., & Zhang, J. (1996). Risk factors for nurs-
5sems
ing home use after hospitalization for medical illness. Journal of
Gerontology Series A-Biotogical Sciences S Medical Sciences.
57(5), M189-M194.
Sager, M,A,, Franke. T, Inouye, S.K., Landefeld, C.S., Morgan, T.M.,
Rudberg, M.A., etal. (1996a). Functional outcomes of acute med-
ical iilness and hospitalization in older persons. Archives of
Internal Medicine. 156(6). 645-652.
Sager, M.A., Rudberg, M.A., Jalaluddin, M., Franke, T. Inouye, S,K.,
Landefeld. C.S.. et al. (1996b}. Hospital admission risk profile
(HARP): Identifying older patients at risk for functional decline fol-
lowing acute medical illness and hospitalization. Journal of the
American Geriatrics Society. 44(3}. 251-257.
Wu, A,W., Yasui. Y, Alzola. C, Galanos, A.N.. Tsevat, J.. Phillips, R.S.,
et al. (2000). Predicting functional status outcomes m hospitalized
patients aged 80 years and older. Journal of the American
Geriatrics Society. 48(5 SuppI.). S6-S15.
Zubek, J.R, Bayer, L,, Milstein. S., & Shephard. J.M. (1969). Behavioral
and physiological changes during prolonged immobilization plus
perceptual deprivation. Journal of Abnormal Psychology. 74(2),
230-236.
SOME NURSES MANAGE MORE
THAN JUST PATIENT CARE. THEY
MANAGE ARMY HOSPITALS.
in fact, some Army Nurses run
Army hospitals. You'll join as a
commissioned officer and others will
look to you for leadership. Simply
put, it's a fast track for nurses
looking to take charge. In addition,
you'll receive:
• Low-cost life insurance
• Worldwide travel oppoftunities
• No-cost or low-cost medical and dental care for you
and yojr family
• Non-contributory retirement benefits with 20 years
of qjalifying service
• 30 days of paid vacation titne earned annjally
To find out more, or to speak to an Army Health Care
Recruiter, call 800-796-8867 or visit
healthcare,goarmy.com/hct/44
©2003. Paid tor b/ trie United States flriry All fights reserved.
AN ARMY OF ONE
163
 Admission and Discharge Mobility of Frail Hospitalized Older Adults

MSN J406 Answer/Evaluation Form:

Admission and Discharge Mobility of Frail
Hospitalized Older Adults
This test may be copied for use by ottiers. Objectives
This educational activity is
designed for nurses and other health
COMPLETE THE FOLLOWING: care professionals who are involved
with the admission and discharge
Name: _ mobility of frail hospitalized older
adults. For those wishing to obtain CE
Address: credit, an evaluation follows. After
studying the information presented in
City: State: .Zip:. this article, the nurse will be able to:
1. Discuss immobility in older adults.
Preferred telephone: (Home)_ (Work). 2. Describe the validity and clinical
usefulness of the Mobility
AMSN Member Expiration Date: Classification Tool on admission
and at discharge.
Registration fee: AMSN/ISONG Member: $ 7.00
Nonmember: $10.00
V y CE Instructions
Answer Form:
I.To receive continuing education
1. Name one new detail (item, issue, or phenomenon) that you credit for individual study after
learned by completing this activity. reading the article, complete the
answer/evaluation form to the left.

2. Detach and send the answer/evalu-

ation form along with a check or
money order payable to AMSN to
2. How will you apply the information from this learning activity to t\AEDSURG Nursing. CE Series, East
Holly Avenue Box 56, Pitman, NJ
your practice?
08071-0056.
a. Patient education.
b. Staff education. 3. Test returns must be postmarked by
June 30, 2006. Upon completion of
c. Improve my patient care.
the answer/evaluation form, a cer-
d. In my educational course work. tificate for 1.7 contact hour(s) will
e. Other: Please describe. be awarded and sent to you.

3. I verify that I have completed this activity.

(Signature)
Evaluation
The offering met the stated objectives.
1. Discuss immobility in older adults.
2. Describe the validity and clinical usefulness
of the Mobility Classification Tool on
admission and at discharge.
3. The material was new for me.
4. Time required to complete reading assignment and posttest:
Comments
This independent study activity is pro-
vided by Anthony J. Jannetti, Inc.,
Strongly Strongly which is accredited as a provider of con-
disagree agree tinuing nursing education by the
American Nurses Credentialing Center's
Commission on Accreditation (ANCC-
COA). Anthony J. Jannetti. Inc. is an
approved provider of continuing educa-
tion by the California Board of
Registered Nursing, Provider #CEP5387.
Minutes This article was reviewed and formatted
for contact hour credit by Dottie
Roberts, MSN, MACI, CMSRN, RN,BC,
ONC, MEDSURG Nursing Editor; and
Sally S. Russell, MN, CMSRN, AMSN
Education Director.

164 MEDSURG Nursing—June 2004—Vol. 13/No. 3

View publication stats