Imagine you’re an 80-year-old who has just had an operation. Lying in bed after a few hours you are starting to wheeze and cough and discolored patches are appearing on your elbows, apparently caused by pushing yourself up onto your pillows. The prospect of pneumonia or pressure ulcers, both associated with extended time in bed, begin to worry you. You ask the nurses to help you get out of bed and walk around the ward, but they are too busy. Fortunately your granddaughter, who is a nurse, also recognises you are deteriorating physically. She helps you out of bed and assists you to get dressed, and then she helps you walk up the ward. She does this for the next few days, each time you go a bit further down the ward. Eventually, your doctor says you can go home, which you do breathing normally and without any pressure ulcers. You have been fortunate, your hospital stay hasn’t harmed you.
Time spent in hospital beds can adversely impact on health, particularly the health of older patients. One reason for this is immobility which causes deconditioning, sapping muscle strength and aerobic capacity. Evidence shows 10 days in hospital leads to the equivalent of 10 years aging in the muscles of people over the age of 80 (Kortebein et al, 2008).
Remaining in hospital unnecessarily compounds deconditioning, as older patients are more likely than younger patients to remain immobile. Reasons for this range from concerns about patients falling to them, particularly patients with dementia, ‘wandering’. Evidence has shown that the less mobile patients are the greater the decline in their ability to perform activities such as washing and dressing, and the greater the likelihood of them being discharged to care or nursing homes (Brown et al, 2004).
Getting people up and moving can be a crucial part of their recovery. If patients get up and walk, evidence shows, they will experience shorter hospital stays (Fisher et al, 2010). However this is not always easy as staff are busy, and patients feel disempowered by the hospital setting. To climb out of a hospital bed to take the few steps to the bathroom without ringing for help, can be frightening for an older person who is sick, in pain, and afraid of falling. Fear of injuries makes staff members and managers nervous too, complaints, litigation, and threats to professional registration lead to risk aversion on their part.
The alarm in relation to the harm caused by immobility has been raised for decades. In addition, doctors, nurses, managers, and other healthcare staff observe for themselves every day how quickly older patients become deconditioned, how even a few days of “bed rest” causes loss of strength and muscle mass, while the risks of blood clots, pressure ulcers and pneumonia increase.
So what can be done to address the issue of deconditioning? A very simple concept advocated by Professor Brian Dolan, Director of Service Improvement, Canterbury District Health Board, New Zealand, and championed by Ann-Marie Riley, Deputy Chief Nurse at Nottingham University Hospitals, suggests that the way we think about the issue of deconditioning can support how to address it.
The concept suggests small changes can be of broad benefit, in this case getting patients out of bed and dressed. Trending under the #endPJparalysis a social movement has developed across hospitals in the United Kingdom which aims to get patients up, dressed and moving by changing the mindset of staff. This has also spread internationally with health staff in Canada, Australia, New Zealand and further afield supporting the principles.Understandably nervousness surrounds the mobilisation of patients in hospital, and falls can indeed be dangerous for older people, but the consequences of prolonged immobility may be worse. Opposition has also been voiced in terms of the time getting patients up and dressed will take. However, many patients can dress themselves, and while visiting family members cannot give their relatives injections or change their IVs, dressing, and walking is something they can take on. And with the voluntary sector also willing to support patients to get dressed and become mobile one could argue the impact on healthcare staff time would be minimal.
The perils of prolonged time in bed for hospital inpatients is well documented. Years ago it was considered a form of treatment, although now beyond some fracture management bed rest as a prescribed treatment is rare (Oliver, 2017). Today it is more likely to be an inadvertent by-product of competing pressures on stretched hospital staff. The median age of inpatients is rising, with pre-existing mobility impairment prevalent on admission (Royal College of Physicians, 2012). Even a few days’ bed rest can cause a rapid decline in muscle strength and aerobic capacity, especially in patients with pre-existing sarcopenia (Kortebein et al, 2008). Therefore, early mobilisation is vital in preventing harm. Doing this by getting patients up and dressed can also, according to Dolan (2017), “ enhance their mental well-being and encourage them to take greater responsibility for their own health and become active participants in their personal health journey”.
Brown GJ, Friedkin RJ, Inouye SK. Prevalence and Outcomes of Low Mobility in Hospitalized Older Patients. Journal of The American Geriatrics Society 2004; 52(8)1263-1270.
Dolan B. Time to change #endPJparalysis#last1000days#Red2Green. The Academy of Fabulous Stuff 2017.
Fisher SR, Kuo Y, Graham JE, Ottenbacher KJ, Ostir GV. Early Ambulation and Length of Stay in Older Adults Hospitalized for Acute Illness. Archives of International Medicine 2010;170(21)1942-1943.
Kortebein P, Symons TB, Ferrnando A, Paddon-Jones D, Ronson O, Protas E, Conger S, Lombeida J, Wolfe R, Evans WJ. Functional impact of 10 days of bed rest in healthy older adults. The journals of gerontology 2008; 63(10):1076-81.
Oliver D. Fighting pyjama paralysis in hospital wards. British Medical Journal 2017;357:2096.
Royal College of Physicians. Hospitals on the edge? The time for action. Sept 2012.
Vincent Baxter is a nurse and senior operational manager, currently on placement with NHS Improvement working as part of the Emergency Care Intensive Support Team.