The purpose of this study was to identify activity factors that contribute to hospital associated functional status decline in older adults with chronic obstructive pulmonary disease (COPD) by promoting functioning during hospitalization.
Background/Significance: COPD is a significant worldwide cause of chronic illness and mortality. The World Health Organization predicts that COPD will become the fourth leading cause of death globally and rank seventh in burden of disease by the year 2030 (Cruz, et al., 2007). COPD is one of the most common admitting diagnoses in the United States, carrying a fifty billion dollar economic burden with the majority of expenses related to hospitalization (HCUP, 2011).
Persons with COPD are at increased risk for deconditioning during hospitalization, which can lead to decreased functional status at discharge (Boltz, et al., 2012). Despite the prevalence of COPD, there are very few studies examining this population for whom mobility is uniquely problematic (Reid et al., 2012). Older adults with COPD are most vulnerable to hospital associated functional status decline (Greening et al., 2014; Liao et al., 2015; Nguyen et al., 2015). To help alleviate the secondary effects of immobility, a clinical nurse specialist-led mobility protocol was developed; however, specific elements of the protocol have not been examined for associated outcomes.
Design: This predictive correlational study is a secondary analysis of a pre-existing dataset. The parent study arose from a hospital unit quality improvement initiative for physical activity and patient outcomes. The parent study measured correlations between an Activity Progression Protocol and hospital length of stay, discharge disposition, falls, pressure ulcer prevalence, oxygen requirements, perceived dypnea, and maximum activity level. The current study analysis explored the number, type, and timing of activity events in relation to the selected functional status outcomes of discharge disposition, length of hospital stay, and 30 day readmission rates for hospitalized older adults with COPD.
Ethics: This study was approved by the authors’ university’s human subject review board.
Sample/Setting: For the parent study, data were collected over a ten month period from patients on a pulmonary unit in a large, tertiary care hospital. The parent study sample included 358 patients admitted during the peak winter months of COPD exacerbation for the northern hemisphere (Donaldson & Wedzicha, 2014). For this secondary analysis, 137 patients with COPD diagnoses were pulled from the larger sample for comparison with non-COPD patients. The subjects with COPD were patients admitted to a pulmonary unit and received a care intervention protocol designed to address mobility barriers related to COPD and hospitalization.
Procedure: The activity protocol was a unit based protocol enacted for all patients admitted to the study unit (Nurse-Administered Pulmonary Protocol Increases Out-of-Bed Activity, Shortens Length of Stay, and Reduces Readmissions, 2009). Mobility was initiated per protocol during the first 24 hours of admission once hemodynamic, neurological, and respiratory stability were achieved. The protocol included screening for readiness, progressive levels of activity, oxygen titration, and use of a rollator for walking support. The nurse-driven protocol for early mobilization was based upon principles of cardiac and pulmonary rehabilitation (Spruit, et al., 2013) and prior study of hospitalized community acquired pneumonia patients (Mundy, et al., 2003).
Analysis: Logistic regression analysis was used to assess the relationship between the number of out of bed activity events, and timing of first out of bed activity and the dichotomous dependent variables of discharge disposition to home versus ECF, and 30 day readmission status. The out of bed activity event data were combined by category as weight bearing (bathroom, up in room, ambulation) and non-weight bearing (bedside commode, dangle, chair) for analysis. Multiple regression was used to assess the relationship between the number, type, and timing of individual out of bed activity events and hospital length of stay. Chi square and ANOVA analyses were used to compare the COPD related diagnoses patient group and patients with non-COPD related diagnoses.
Preliminary results show weight bearing activities (ambulation, up to bathroom, up in room) have a significant effect on discharge disposition to home (p=0.012). The probability of discharge to home increases for each additional weight bearing activity per day (p<0.001). Activities with the greatest effect upon discharge to home are ambulation (p=0.0003), up to the bathroom (p=0.021), and bedside commode (p=0.031), in that order. Getting up to the bathroom, however, is nearly seven times more likely to affect discharge to home than bedside commode activity. For each additional weight bearing activity (bathroom, up in room, ambulation) per day, we expect to see the length of stay decrease by 1.69 days. For each additional ambulation per day, we expect to see the length of stay decrease by 3.8 days. For each additional day to the first out of bed activity, we expect the length of stay to increase by 1.07 days. For each additional day to first out of bed activity, we expect the odds of discharge to home to decrease by 14 to 36.2 percent on average.
No activities were found to have a significant effect on 30 day readmission (individually or categorized). The number of days to first out of bed activity was not significant for 30 day readmission.
Preliminary results of group differences in outcomes show COPD patients are less likely to be readmitted within 30 days as compared to non-COPD patients and more likely to be discharged to home as compared to non-COPD patients in this sample. Advancing age affects non-COPD patients to a greater degree than COPD patients with regard to effect upon likelihood of discharge to home. Group differences with regard to specific activities, time to first out of bed activity, and comorbidity influence are still being analysed and results may shed light upon the differences in outcomes of these two groups.
The preliminary findings of this study demonstrated that out of bed physical activities are associated with shortened hospital length of stay and improved patients’ likelihood of discharge to home for older adults with COPD.
Implications for Practice: Nurses should place emphasis on and direct resources toward daily weight bearing activities (ambulation, up to bathroom) to improve outcomes and preserve functional status during hospitalization. Nurses are in a unique position to drive efforts to prevent such decline given their continual presence at the bedside and primary responsibility for physical activity while the patient is hospitalized.