Early mobility after fragility hip fracture: a mixed methods embedded case study

Abstract

Background Following a hip fracture up to 60% of patients are unable to regain their pre-fracture level of mobility. For hospitalized older adults, the deconditioning effect of bedrest and functional decline has been identified as the most preventable cause of ambulation loss. Recent studies demonstrate that this older adult population spends greater than 80% of their time in bed during hospitalization, despite being ambulatory before their fracture. We do not fully understand why there continues to be such high rates of sedentary times, given that evidence demonstrates functional decline is preventable and early mobility recommendations have been available for over a decade. Methods A descriptive mixed method embedded case study was selected to understand the phenomenon of early mobility after fragility hip fracture surgery. In this study, the main case was one post-operative unit with a history of recommendation implementation, and the embedded units were patients recovering from hip fracture repair. Data from multiple sources provided an understanding of mobility activity initiation and patient participation. Results Activity monitor data from eighteen participants demonstrated a mean sedentary time of 23.18 h. Median upright time was 24 min, and median number of steps taken was 30. Qualitative interviews from healthcare providers and patients identified two main categories of themes; themes external to the person and themes unique to the person. We identified four factors that can influence mobility; a patient’s pre-fracture functional status, cognitive status, medical unpredictability, and preconceived notions held by healthcare providers and patients. Conclusions There are multi-level factors that require consideration with implementation of best practice interventions, namely, systemic, healthcare provider related, and patient related. An increased risk of poor outcomes occurs with compounding multiple factors, such as a patient with low pre-fracture functional mobility, cognitive impairment, and a mismatch of expectations. The study reports several variables to be important considerations for facilitating early mobility. Communicating mobility expectations and addressing physical and psychological readiness are essential. Our findings can be used to develop meaningful healthcare provider and patient-centred interventions to address the risks of poor outcomes.

Facilitators and barriers to enhancing physical activity in older patients during acute hospital stay: a systematic review

“…The methodological quality of qualitative studies ranged from a score of 3 to 5, of which three studies were categorized as low quality [ 59 , 68 , 87 ], and 15 studies were categorized as high quality [ 43 , 52 , 54 , 61 – 63 , 65 – 67 , 71 , 81 , 82 , 86 , 88 , 89 ]. For the mixed-methods studies, the total methodological quality scores varied from no score to a score of 2, with all 11 studies categorized as low quality [ 60 , 70 , 72 , 75 – 80 , 83 , 84 ].…”

“…Common facilitators of PA of theme 1 ‘patients’ knowledge, awareness and attitude’ were: patients’ positive attitudes, or expectations toward mobilization [ 52 , 61 , 76 , 80 , 81 ]. Furthermore, patients’ awareness of the need for mobility [ 59 , 60 , 88 , 89 ], patients who want to promote functional recovery [ 54 , 59 , 77 , 84 ], and perceived benefits due to mobilization were facilitators [ 52 , 54 , 60 , 76 , 87 ]. Facilitators of theme 2 ‘physical health’ were: sufficient baseline functional status scores, or sufficient baseline PA level of patients [ 42 , 50 , 55 , 57 , 84 , 85 ].…”

“…Furthermore, patients’ awareness of the need for mobility [ 59 , 60 , 88 , 89 ], patients who want to promote functional recovery [ 54 , 59 , 77 , 84 ], and perceived benefits due to mobilization were facilitators [ 52 , 54 , 60 , 76 , 87 ]. Facilitators of theme 2 ‘physical health’ were: sufficient baseline functional status scores, or sufficient baseline PA level of patients [ 42 , 50 , 55 , 57 , 84 , 85 ]. Facilitators of theme 3 ‘medical-related factors’ were: improving medical status or no acute complications [ 45 , 50 ], and lower illness severity scores [ 55 , 57 ].…”

“…Furthermore, patients refused to move [ 49 , 51 ], or they preferred to stay in bed, because they believed it would contribute to aiding recovery [ 60 , 80 , 81 , 88 ]. Barriers of theme 2 ‘physical health’ were: patients’ fears, in particular fear of falling [ 43 , 51 , 60 , 82 , 84 , 86 , 88 ], fear of burden to nurse when falling [ 88 ], and fear of injury [ 51 , 54 , 59 , 84 ]. Furthermore, frequently reported barrier was patients with poor or impaired physical health status [ 52 , 81 , 86 , 89 ].…”

“…Furthermore, frequently reported barrier was patients with poor or impaired physical health status [ 52 , 81 , 86 , 89 ]. Specifically, patients having symptoms such as pain, dyspnea, dizziness, feeling ill, or fatigue [ 42 , 43 , 48 , 51 , 54 , 60 , 61 , 76 , 82 , 84 , 85 , 87 ]. On theme 3 ‘medical-related factors’ was the presence of lines or attachments that hindered patients walking a barrier, such as catheters [ 45 , 50 , 51 , 54 , 59 , 60 , 81 , 82 ].…”