Rehabilitation is a cornerstone of post-stroke recovery1. However, studies investigating when and how to begin rehabilitation through early mobilization after stroke have had varying results. Most recently, a prospective trial investigating very early mobilization, within 24 hours from stroke onset, suggested worse clinical outcomes in their cohort2. A dose-finding subgroup analysis of this study, however, suggested benefit of very early mobilization if the mobility intervention was shorter in duration.3 These findings were more consistent with previous trials about early mobilization of stroke patients.4,5,6 These conflicting evidences about the benefits of early mobilization after stroke likely contribute to the phenomenon of prolonged bedrest during their stroke hospitalization. With patients spending more time in bed in the first few days after stroke, we are likely underutilizing a critical period of early post-stroke recovery for hospitalized stroke patients resulting in long term effect on stroke-related disability and quality of life,7,8,9,10. Worse, prolonged bedrest has negative effects on recovery through deconditioning, the potential for deep vein thrombosis (VTE) development, and effect on pulmonary function.
Stroke patients remain hospitalized for several reasons: diagnostic evaluation of stroke etiology, monitoring of post-stroke complications and initiation of stroke prevention treatments. Nursing care focuses on detailed neurological assessments, monitoring of comorbid conditions, administering medications, arranging for tests, and patient education about recovery and secondary stroke prevention. Rehabilitation provided during this period is under-prioritized and is often focused more on discharge planning than for enhancing recovery5. Therefore, we wished to understand staff perceptions of early mobilization after stroke in our comprehensive acute stroke center to inform a future prospective study of a nurse-led, progressive mobility program for hospitalized stroke patients. Encouraging early activity during this complex period of post-stroke recovery may require a shift in current thought process and planning from health care providers.
Purpose:
The purpose of this study was to understand perceptions from multiple disciplines about early mobilization of hospitalized stroke patients.
Methods:
Our interdisciplinary early stroke recovery team designed a survey to triangulate information about physiological, environmental and staff knowledge specific to early mobilization of acute stroke patients. This team consists of nurses, physical therapists (PT), occupational therapists (OT), a nurse educator, and a stroke neurologist who meet weekly to direct early stroke rehabilitation initiatives in the inpatient setting. A judgement study sample was obtained which included stroke physicians, neurology residents, neuroscience nurses, neuroscience clinical technicians, PT and OT staff working with patients during August 2017.
In this survey, we provided 50 patient conditions asking staff to respond how likely they would mobilize a stroke service patient using a 4-item Likert response scale. These patient conditions focused on intrinsic factors such as vital signs, lab results, cardiac rhythms, functional level and attachments of medical devices. We asked 12 extrinsic factors such as equipment availability, patient availability, assistance availability, staff confidence, provider activity orders, and sufficient time to perform mobility activities. The secure web application, REDCap, was used to send survey invitations to a group of 163 participants from our judgement study sample. Data collection was completed in an urban, academic comprehensive stroke care setting after approval with our Institutional Review Board.
Results:
Of the 163 participants contacted, 77 (47%) respondents completed the survey, with 1 incomplete survey response. The responses were provided by 20 (26%) physicians, 24 (31%) nurses, 4 (5%) clinical technicians, 19 (24%) PT/ PT assistants, and 11 (14%) OT/ OT assistants. Of the questions targeting intrinsic factors of early mobility, 91% would mobilize patients who were low fall risk status and 86% of staff agreed that they would mobilize patients with pain scores of 1-3. Of those who responded, 81% of staff would not mobilize a patient with systolic blood pressure greater than 220 mmHg.
Aside from these conditions with high staff agreement, responses to other questions yielded variable results. Some conditions with heterogeneous responses included conditions mobilizing a stroke patient with orthostatic hypotension: 65% of respondents would not mobilize patients compared to 34% who would. When these responses were divided by disciplines, the variability persisted. Another condition with heterogeneous responses was mobilizing a stroke patient with new venous thromboembolism (VTE) while not on anticoagulation therapy: 32% “definitely won’t”, 41% “probably won’t”, 23% “probably will”, and 3.8% “definitely won’t”. Physician responders demonstrated the most inconsistency with 40% stating that they “probably won’t” and 40% selecting “probably will” such a patient. Clinical technicians also had two common responses with 50% selecting “probably won’t” and 50% selecting “probably will”.
Discussion:
Our survey of multidisciplinary stroke providers demonstrated high variability in responses to physiological scenarios about when to mobilize a stroke patient. The highest degree of variability, suggesting uncertainty in practices related to situations of orthostasis and presence of VTE. When these responses were divided according to disciplines, the mode response varied between the disciplines, suggesting an area for potential education and improving communication related to mobility decisions among staff.
A limitation to our survey was the low representation of clinical technicians. We hypothesize since the survey invitation and reminders were sent via email, those who checked their email accounts less often were not included. Clinical technicians play a vital role in the mobilization of patients, and lack of their input could affect our survey results. Another limitation could be the nature of the survey which purposefully isolated single patient factors for each question. The decision to mobilize a hospitalized acute stroke patient is complex and multifactorial. Our survey is limited in capturing the true complexity for a clinician to decide whether they feel comfortable to mobilize a stroke patient. More qualitative data collection such as one on one interviewing further understanding the clinician perspective. This area requires further study in order to better understand the contributors to successful early mobilization in order to optimize patient care and reduce stroke related disability5, 7.
Conclusion:
This study focused on factors determining early mobilization of stroke patients revealed a high level of uncertainty around two common intrinsic patient features: orthostatic hypotension and VTE. These data will be merged with objective data collected over a one year period about the timing of first mobilization of acute stroke patients in our specialty stroke unit. This combined qualitative and quantitative data will be foundational as we design future clinical studies of innovative programs to enhance best practice and earlier mobilization in order to reduce bedrest in this vulnerable population of patients.