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Physical activity levels and patients’ expectations of physical activity during acute general medical admission N. Cattanach, R. Sheedy, S. Gill and A. Hughes Internal Medicine, Barwon Health, Geelong, Victoria, Australia

Key words physical activity, acute, medical patient, expectations. Correspondence Andrew Hughes, Barwon Health, Department of Medicine, Bellerine Street, Geelong, Vic. 3220, Australia. Email: [email protected] Received 7 August 2013; accepted 5 January 2014. doi:10.1111/imj.12411

Abstract Bedrest during hospital admission is common and might be harmful. There is scarce published evidence that quantifies physical activity levels and expectations regarding physical activity of general medical patients during an acute inpatient stay. The current study aimed to investigate physical activity levels and expectations regarding physical activity in general medical patients at a large Australian teaching hospital. A convenience sample of 24 general medical patients was observed at 10-min intervals in one day between 8:00 and 17:00 and their physical activity status recorded. Participants completed a questionnaire regarding their expectations of physical activity during illness and hospital admission. Patients were observed to be in bed 51% of the time, were sitting out of bed 43% of the time, were standing 1% of the time and were walking 5% of the time. One third of participants (n = 8) were not observed to walk during the observation period. Questionnaire data indicated that nine (38%) participants expected to remain in bed while in hospital. General medical patients had low levels of physical activity during their hospital stay, which was consistent with many participants’ expectations of appropriate activity when in hospital. If physical activity is an important part of acute general medical patient management, then patient expectations of the appropriateness of physical activity need to be addressed and methods to increase physical activity implemented.

Functional decline is the leading adverse effect of hospitalisation in the elderly.1–3 Thirty-four to fifty percent of older adults experience functional decline during hospital admission, which might be unrelated to their primary diagnosis.4,5 Bed-based hospital care is common,1 but for many conditions bedrest has no benefits and might be harmful.6 Bedrest is associated with adverse cardiovascular, respiratory and musculoskeletal effects,7 including venous thromboembolism,8 pneumonia,9 urinary infections,10 pressure ulcers11,12 and falls.13 Bedrest is rarely indicated as part of inpatient treatment.14 Early mobilisation of patients to prevent the detrimental effects of bedrest and promote recovery is recommended, including for some critically ill patients in intensive care units.15–18 Despite recommendations to be physically active during hospital admission, a small

Funding: None. Conflict of interest: None. © 2014 The Authors Internal Medicine Journal © 2014 Royal Australasian College of Physicians

number of studies reported that bedrest and low levels of physical activity is common in hospital patients.7,19,20 The current study had two main aims: (i) quantify the amount and type of physical activity in general medical hospital inpatients; and (ii) identify patients’ expectations of being physically active when in hospital. Barwon Health Human Research Ethics committee approved the study. All participants provided informed consent. The study was conducted at Geelong Hospital, a 432-bed teaching hospital servicing an urban and rural population of approximately 500 000 people across southwestern Victoria. The Geelong Hospital has five general medical teams and admits an average of 12 patients per day into two medical wards and a short-stay unit. Common diagnoses for general medical patients include chest infection, asthma, urinary tract infection, fall or syncope. Most patients are older adults with an average age of 69 years and have an average length of stay of 5.5 days. Junior doctors and nurses are encouraged by senior staff to 501

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facilitate early mobilisation of patients for the prevention of functional decline. Walking routes are marked on wards and posters are displayed that encourage physical activity. Included patients were 18 years of age or older, were admitted to a general medical ward, were not receiving palliative care treatment and were cognitively alert such that they could understand the purpose of the study, and read and respond to the questionnaire. Patients were excluded if they were to be discharged on the day of data collection. Patients were approached while in their hospital rooms and invited to participate in the study. Patients were recruited from the two general medical wards and one short-stay unit. The first two rooms in each ward with four eligible patients were selected for recruitment. Behavioural mapping was used to observe and quantify patients’ physical activity.21 On each observation day, eight patients were observed from 8:00 to 17:00.16 One observer (NC) recorded observations every 10 min, with the exception of five 10-min breaks scheduled intermittently throughout the day. During the 10-min intervals, 4 min were spent in each room observing the maximum activity level of the four patients in that room. Two minutes were spent moving between the two rooms.22,23 The patient was recorded as undertaking one of four activities: (i) resting in bed; (ii) sitting out of bed; (iii) standing activities; or (iv) walking. The highest level of activity observed for each patient was recorded. Patients and staff were informed that the observer would monitor patients throughout the day to improve the organisation’s understanding of how patients spend their day and subsequently improve patient care. Patients were encouraged not to change their behaviour due to the observer’s presence and were not informed that physical activity in particular was being monitored. If a patient was not in the room during the observation period, this observational period was not included for the patient. Three authors (NC, RS, AH) designed a five-item questionnaire to assess patients’ pre-admission physical activity levels and expectations regarding physical activity when in hospital (see Table 1 for questionnaire items). Behavioural mapping and questionnaire data were analysed with descriptive statistics using Microsoft Excel. The first 24 participants invited to participate provided informed consent and were recruited to the study. Participants were admitted for conditions such as lower respiratory tract infection, cardiac failure, urinary tract infection and cellulitis. Participants’ mean age was 77 years (range 33–91). Fourteen (58%) participants were female. Twenty-two (92%) participants were walking independently prior to admission and 18 (75%) partici502

Table 1 Pre-admission activity levels and expectations for activity during admission n (%) Physical activity levels at home when well Sedentary (little or no exercise) Lightly active (light exercise 1–3 days/week) Moderately active (moderate exercise 3–5 days/week) Very active (hard exercise 6–7 days/week)

7 (29.2) 6 (25) 8 (33.3) 3 (12.5)

Physical activity levels at home when unwell Sedentary Lightly active Moderately active Very active

14 (58.3) 10 (41.7) 0 (0) 0 (0)

Expectations of physical activity during hospital admission and unwell Rest in bed until well Do light activity until well Keep active

9 (38) 13 (54.2) 2 (8.3)

Staff should encourage physical activity in hospital Disagree Somewhat agree Agree

2 (8.3) 7 (29.2) 15 (62.5)

pants were able to walk without another person’s assistance at the time of the study. No participant was prescribed bedrest. Participants’ median length of stay prior to enrolment was 3 days (range 1–21 days). Five participants were unexpectedly discharged from hospital prior to completion of the day’s observation, which resulted in 94 min of observation time being lost for those participants. All 24 participants completed the questionnaire. One hundred and forty-seven participant observation periods were made during 1082 min of observation. Participants were observed resting in bed 51% of the time, sitting out of bed 43% of the time, standing 1% of the time and walking 5% of the time. Eight participants (33%) were not observed walking, four of whom could walk without assistance from others. Patients who were able to walk without another person’s assistance were in bed 50% of the time, sitting out of bed 44% of the time and walking 5% of the time (Fig. 1). Participants who required assistance to walk had similar activity levels (Fig. 1). Seven (29%) participants reported being sedentary (little or no exercise) when at home and well (Table 1). Fourteen (58%) participants reported being sedentary when at home and unwell. When in hospital, nine (38%) participants expected to rest in bed until well. Of the nine participants who expected total bedrest while in hospital, four participants agreed that hospital staff should encourage patients to do things for themselves. © 2014 The Authors Internal Medicine Journal © 2014 Royal Australasian College of Physicians

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Figure 1 Activity status of people who could walk independently versus those who needed assistance to walk (dependent). SOOB, sitting out of bed. ( ), Dependent participants; ( ), independent participants.

Functional decline during hospitalisation is common.1 Bedrest and physical inactivity could be a leading cause of functional decline during hospitalisation.6,19,22 Contrary to guidelines recommending mobilisation21 and our hospital’s attempts to encourage patients to be physically active, the results of the current investigation indicated that participants were inactive for most of the day and that many participants expected to rest in bed until they were well. Bedrest is common during hospital admission. The results of the current investigation are similar to others who found that hospital patients spend most of the day in bed.20,23,24 The ability to walk independently does not appear to decrease the amount of time spent in bed suggesting that factors other than physical ability determine activity levels. When in hospital, more than one third of our participants expected to rest in bed until well. Patients’ tendencies to be inactive when well, together with their expectations for bedrest during illness, could be important contributors to being inactive during hospitalisation. Replacing patients’ expectations of bedrest with the importance of being physically active is likely to be a crucial step towards increasing patients’ physical activity when in hospital. In addition to patients’ expectations of bedrest during hospitalisation, other barriers to physical activity exist. Brown et al. interviewed 29 patients and staff

© 2014 The Authors Internal Medicine Journal © 2014 Royal Australasian College of Physicians

in a hospital medical ward and discovered barriers to activity included pain, fatigue, weakness, and concern about falling.25 Environmental barriers included having an intravenous line or urinary catheter, and lack of staff to help patients requiring assistance. Staff, not patients, attributed low activity to lack motivation and lack of mobility devices.25 Barriers to physical activity during hospitalisation are multifactorial. Interventions to increase activity must consider environmental, staff and patient-related factors. Methods to increase patients’ physical activity might include: providing ‘consumer-centred’ education of the benefits of physical activity; capping IV lines; lowering bed rails; optimising analgesia; providing appropriate mobility aids, staff assistance, and clothing; designating times and physical spaces to be active; and enabling family or carer participation in patient physical activity. The bed is the dominant feature in patient rooms, and there is often no purposeful destination to ambulate to. Rather than ‘wandering the corridors’, providing accessible environments that encourage out-of-bed activity, such as gymnasiums and places for socialisation, might increase patients’ physical activity. Rehabilitation patients do more activity when therapy is supervised and spend very little time in self-directed therapy,26 suggesting that patients might need formal structured exercise sessions to increase physical activity. However, a systematic review found there is currently not enough evidence to be certain of the benefits and harms of exercise sessions for older hospitalised adults.1 Jones et al. found that 30 min of twice daily supervised exercise improved physical function and reduced length of stay when compared to usual care in 180 acute general medical patients aged 65 years or older.27 De Morton et al. found no differences between usual care and twice daily supervised exercise sessions in 236 acute medical patients aged 65 or older with respect to discharge destination, activity limitation, length of stay or adverse events.1,28 Further investigations are required to clarify the effects of physical activity in general medical patients, including the benefits of supervised exercise, the optimum type and amount of physical activity, and if some conditions might benefit from bedrest. The current study has limitations. Researcher observation might have altered participant and staff behaviour. Intermittent observation might not accurately capture a patient’s activity levels during unobserved periods. Our convenience sample was small and the results might not generalise to all general medical patients in our hospital.

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12 Allman R, Goode P, Martha P. Pressure ulcer risk factors among hospitalized patients with activity limitation. J Am Med Assoc 1995; 273: 865–70. 13 Mahoney J. Immobility and falls. Clin Geriatr Med 1998; 14: 699–726. 14 Clinical Epidemiology and Health Service Evaluation Unit. Evidence Based guidelines: prevention of functional decline in elderly patients: Royal Melbourne Hospital. 2005. [cited 2013 Nov 18]. Available from URL: http:// www.mh.org.au/royal_melbourne _hospital/secure/downloadfile.asp?fileid =1001784 15 Needham DM. Mobilizing patients in the intensive care unit: improving neuromuscular weakness and physical function. JAMA 2008; 300: 1685–90. 16 Truong AD, Fan E, Brower RG, Needham DM. Bench-to-bedside review: mobilizing patients in the intensive care unit – from pathophysiology to clinical trials. Crit Care 2011; 13: 216. 17 Gosselink R, Bott J, Johnson M, Dean E, Nava S, Norrenberg M et al. Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients. Intensive Care Med 2008; 34: 1188–99. 18 Clinical Epidemiology and Health service Evaluation Unit. Best Practice Approaches to Minimize Functional Decline in The Older Person Across The Acute, Sub-Acute and Residential Aged Care Setting. Melbourne, Victoria: Victorian Government Department of Human Services. 2004. [cited 2013 Nov 18]. Available from URL: http://docs.health.vic.gov.au/ docs/doc/B7EBD633505C09E5CA 257852000F0D42/$FILE/functional -decline-manual.pdf. 19 Bernhardt J, Clitravas N, Lidarende Meslo I, Thrift A, Indredavik B. Not All stroke units are the same – a comparison of physical activity patterns in Melbourne, Australia, and

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Trondheim, Norway. Stroke 2008; 39: 2059–65. Brown CJ, Friedkin RJ, Inouye SK. Prevalence and outcomes of low mobility in hospitalized older patients. J Am Geriatr Soc 2004; 52: 1263–70. Ittelson WH, Rivlin LG, Proshanky HM. The use of behavioral maps in environmental psychology. In: Proshansky HM, Ittleson WH, Rivlin LG, eds. Environmental Psychology: People and Their Physical Settings. 1997; 340–51. Gill TM, Allore H, Guo Z. The deleterious effects of bed rest among community-living older persons. J Gerontol A Biol Sci Med Sci 2004; 59: 755–61. Pedersen M, Bodilsen AC, Petersen J, Beyer N, Andersen O, Lawson-Smith L et al. Twenty-four-hour mobility during acute hospitalization in older medical patients. J Gerontol A Biol Sci Med Sci 2013; 68: 331–7. Callen BL, Mahoney JE, Grieves CB, Wells TJ, Enloe M. Frequency of hallway ambulation by hospitalized older adults on medical units of an academic hospital. Geriatr Nurs (Minneap) 2004; 25: 212–17. Brown CJ, Williams BR, Woodby LL, Davis LL, Allman R. Barriers to mobility during hospitalization from the perspectives of older patients and their nurses and physicians. J Hosp Med 2007; 2: 305–13. Newall JT, Wood VA, Hewer RL, Tinson DJ. Development of a neurological rehabilitation environment: an observational study. Clin Rehabil 1997; 11: 146–55. Jones CT, Lowe AJ, Macgregor L, Brand C. A randomized controlled trial of an exercise intervention to reduce functional decline and health service utilization in the hospitalized elderly. Australas J Ageing 2006; 25: 126–33. de Morton NA, Keating JL, Berlowitz DJ, Jackson B, Lim WK. Additional exercise does not change hospital or patient outcomes in older medical patients: a controlled clinical trial. Aust J Physiother 2007; 53: 105–11.

© 2014 The Authors Internal Medicine Journal © 2014 Royal Australasian College of Physicians

Physical activity levels and patients' expectations of physical activity during acute general medical admission.

Bedrest during hospital admission is common and might be harmful. There is scarce published evidence that quantifies physical activity levels and expe...
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