Mobilization. When I was on the dark side (not geri-friendly), I used to think that writing orders like mobilization TID would make my practice very senior-friendly. It might make sense on a hospital unit, but in the ED, does it?
Our older adults move (I should say, roll) from one test to another, an IV here, oxygen there, “I want to go to the bathroom” but no one is available to help. They are often physically restrained, and this is all because of us. Iatrogenic! But is there really harm done by leaving them “rest” in their bed with rails up? Oh yes! You might as well say may they “rest in peace”. It is deadly. Let’s review a few stats.
- For each hour of immobilization in the ED, 3% increased risk of adverse events and prolonged hospital stay (1).
- Prolonged bed rest in older patient can lead to substantial loss of muscle, strength and physical activity (British geriatric society).
- Immobilization can leads to increased confusion, demotivation and fear of getting out of bed.
- Reconditionning takes twice the amount of time.
Let’s stop here and talk about solutions. That is the great thing about geriatrics, we can ALWAYS do better!
Physiotherapy could be an option to add in your ED while patients are waiting to be admitted on the ward. What evidence is behind it? Not much. I even read a review about adding physiotherapist in the ED and listen to their silly conclusion: “At system and provider levels, there is insufficient evidence to support benefits of an emergency department physiotherapy service. At patient level, there is high-level evidence of benefits in terms of improved pain control and reduced disability in the short term. (2)»
The senior-friendly person in me find that outrageous. There are evidences about benefit FOR THE PATIENT, isn’t that what we are looking for?
I found others studies that support the prevention of immobilization syndrome when the physiotherapy is started in the ED (3-5).
There are others solutions:
- You will always find some volunteers who would want to help. Is it safe? Yes, probably, with simple basics instructions.
- Give your patient the possibility to have access their glasses, hearing aids, a walker and an aid for the bathroom at all time. Do not put a toilet chair in their room if they are able to go to the bathroom with one aid, this contribute to the immobilization syndrome and encourage our patient to do as little as possible.
- Remove IV, urinary catheter as soon as possible.
- Encourage them to sit up every chance they have, when listening to the chest for your exam, for their meals, etc.
- Keep them dressed in their own clothes if possible.
- Educate families and staff (there is this erroneous theory that rest is good for recovery).
- Every time you see them for a lab results or an update, make them move.
- Take care of the pain. They sometime have some MSK pain that prevent them to move, acetaminophen 1g TID, and start from there.
So, mobilization TID? No, mobilization all the time. Be part of this movement, be the ambassador against deconditioning, advocate for the maintenance of their functional status, educate families and staff and engage your department, mobility-friendly ED?
- Ackroyd-Stolarz S, Read Guernsey J, Mackinnon NJ, Kovacs G. The association between a prolonged stay in the emergency department and adverse events in older patients admitted to hospital: a retrospective cohort study. BMJ quality & safety. 2011 Jul;20(7):564-9. PubMed PMID: 21209130.
- Kilner E. What evidence is there that a physiotherapy service in the emergency department improves health outcomes? A systematic review. Journal of health services research & policy. 2011 Jan;16(1):51-8. PubMed PMID: 21186320.
- Tousignant-Laflamme Y, Beaudoin AM, Renaud AM, Lauzon S, Charest-Bosse MC, Leblanc L, et al. Adding physical therapy services in the emergency department to prevent immobilization syndrome – a feasibility study in a university hospital. BMC emergency medicine. 2015 Dec 03;15:35. PubMed PMID: 26635006. Pubmed Central PMCID: 4669664.
- Crane J, Delany C. Physiotherapists in emergency departments: responsibilities, accountability and education. Physiotherapy. 2013 Jun;99(2):95-100. PubMed PMID: 23219643.
- Anaf S, Sheppard LA. Describing physiotherapy interventions in an emergency department setting: an observational pilot study. Accident and emergency nursing. 2007 Jan;15(1):34-9. PubMed PMID: 17118659.