Nutrition Support Blog – Keep Them Moving! (or Avoiding “Iatrogenic Disability”)
February 5, 2013
My latest mission, I will tell you, is to not allow patients to lie in bed waiting for something to happen. The reality is, that lying passively in bed zaps our patients' strength and adds to their rehab “sentence” (hospitalized patients really do become the consummate couch potato, don’t they?). But we, as clinicians, are partly to blame. The truth is we don’t tell our patients how to be patients. We do not give them a guidebook on what our expectations are of them while they are in the hospital under our care, so—HOW CAN THEY KNOW?? Let me share a personal anecdote from whence this “new mission” arose. My mother was in assisted living for 15 years (this was no small feat, but I will spare the details) after a significant stroke left her with total left hemiparesis. What I would like to share is something so ridiculously simple that you will think, “Duh! It does not take rocket science", or maybe, “How could that have happened?”
My mother was walked at her assisted living facility with assistance 3 times a week with her hemi-walker. Ownership of her facility changed and over time so did the wonderful staff as well as other things, one of which was the walking of my mother. My mother did not think to say anything to her kids, and after three months, we got a call from the facility saying that she was now a 2 person transfer, instead of 1, and should really go into a nursing home. It was then that we found out they had stopped walking her 3 months earlier! After a PT consult, a plan to walk her 3 times a week again began. Two months later, she was back to walking 30 feet with her hemi-walker with assistance and transferring with one person.
This is no different than our patients coming in from the outside, walking and having a life, to suddenly be thrust into a hospital bed, and not knowing they should keep moving, they lie and wait…
In talking with physical therapy, they would love some help as they cannot see everyone, but we can certainly have a conversation with our patients once we know their limitations. Once I have cleared with a patients nurse or physician that mobility is not restricted I will:
1) Explain to them why it is important not to lie in bed
2) If on nutrition support, transition them to bolus or nocturnal feeding (if possible) to facilitate mobility, and/or get rid of IV fluids if possible.
3) Encourage them to sit up for all meals (or better yet, transfer into their chair to eat!) and
4) Walk the halls 2 - 3 times a day.
5) And if you can do even more than that, you need to be discharged! :)
It takes a village to feed our patients, so too does it take a village to keep our patients moving to avoid iatrogenic disability. Besides, how can our patients gain muscle if they do not use them!
1) Krumholz HM. Post-hospital syndrome--an acquired, transient condition of generalized risk. N Engl J Med. 2013 Jan 10;368(2):100-2.
2) Lafont C, Gérard S, Voisin T, et al; Members of I.A.G.G./A.M.P.A. Task Force. Reducing "iatrogenic disability" in the hospitalized frail elderly. J Nutr Health Aging. 2011;15(8):645-60.
3) Covinsky KE, Pierluissi E, Johnston CB. Hospitalization-associated disability: "She was probably able to ambulate, but I'm not sure." JAMA. 2011;306(16):1782-93.