The impact of delayed mobilization on post-discharge outcomes after emergency abdominal surgery: A prospective cohort study in older patients

Jenelle L Pederson, Raj S Padwal, Lindsey M Warkentin, Jayna M Holroyd-Leduc, Adrian Wagg, Rachel G Khadaroo, Jenelle L Pederson, Raj S Padwal, Lindsey M Warkentin, Jayna M Holroyd-Leduc, Adrian Wagg, Rachel G Khadaroo

Abstract

Surgeons are increasingly treating seniors with complex care needs who are at high-risk of readmission and functional decline. Yet, the prognostic importance of post-operative mobilization in older surgical patients is under-investigated and remains unclear. Thus, we evaluated the relationship between post-operative mobilization and events after hospital discharge in older people. Overall, 306 survivors of emergency abdominal surgery aged ≥65y who required help with <3 activities of daily living were prospectively followed at two Canadian tertiary-care hospitals. Time until mobilization after surgery was attained from hospital charts and a priori defined as 'delayed' (≥36h) or 'early' (<36h). Primary outcomes for 30-day and 6-month all-cause readmission/death after discharge were assessed in multivariable logistic regression. Patients had a mean age of 76 ± 7.7 years, 45% were women, 41% were 'vulnerable-to-moderately-frail', according to the Clinical Frailty Scale. Most common reasons for admission were gallstones (23%), intestinal obstructions (21%), and hernia (17%). Median time to post-operative mobilization was 19h (interquartile range 9-35); 74 (24%) patients had delayed mobilization. Delayed mobilization was independently associated with higher risk of 30-day readmission/death (19 [26%] vs. 22 [10%], P<0.001; adjusted odds ratio [aOR] 2.24, 95%CI 0.99-5.06, P = 0.05), but this was not statistically significant at 6-months (38 [51%] vs. 64 [28%], P<0.001; aOR 1.72, 95%CI 0.91-3.25, P = 0.1). One-quarter of older surgical patients stayed in bed for 1.5 days post-operatively. Delayed mobilization was associated with increased risk of short-term readmission/death. As older, more frail patients undergo surgery, mobilization of older surgical patients remains an understudied post-operative factor. Trial registration: clinicaltrials.gov identifier: NCT02233153.

Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1. Flow diagram of cohort.
Fig 1. Flow diagram of cohort.
Fig 2. Readmission or death after surgical…
Fig 2. Readmission or death after surgical discharge, according to time of mobilization.

References

    1. Kortebein P, Symons TB, Ferrando A, Paddon-jones D, Ronsen O, Protas E, et al. Functional Impact of 10 Days of Bed Rest in Healthy Older Adults. J Gerontol A Biol Sci Med Sci. 2008;63(10):1076–81. 10.1093/gerona/63.10.1076
    1. Dittmer DK, Teasell R. Complications of immobilization and bed rest. Part 1: Musculoskeletal and cardiovascular complications. Can Fam Physician. 1993;39:1428–32, 1435–7.
    1. Kalisch BJ, Lee S, Dabney BW. Outcomes of inpatient mobilization: A literature review. J Clin Nurs. 2014;23(11–12):1486–501. 10.1111/jocn.12315
    1. Pashikanti L, Von Ah D. Impact of Early Mobilization Protocol on the Medical-Surgical Inpatient Population. Clin Nurse Spec. 2012;26(2):87–94. 10.1097/NUR.0b013e31824590e6
    1. Epstein N. A review article on the benefits of early mobilization following spinal surgery and other medical/surgical procedures. Surg Neurol Int 2014;5:S66–73. 10.4103/2152-7806.130674
    1. Castelino T, Fiore JF, Niculiseanu P, Landry T, Augustin B, Feldman LS. The effect of early mobilization protocols on postoperative outcomes following abdominal and thoracic surgery: A systematic review. Surgery. 2016;159(4):991–1003. 10.1016/j.surg.2015.11.029
    1. Kalisch BJ, Landstrom G, Williams RA. Missed nursing care: Errors of omission. Nurs Outlook. 2009;57(1):3–9. 10.1016/j.outlook.2008.05.007
    1. Covinsky KE, Pierluissi E, Johnston CB. Hospitalization-Associated Disability “She Was Probably Able to Ambulate, but I’m Not Sure.” JAMA. 2011;306(16):1782–93. 10.1001/jama.2011.1556
    1. Brown CJ, Redden DT, Flood KL, Allman RM. The underrecognized epidemic of low mobility during hospitalization of older adults. J Am Geriatr Soc. 2009;57(9):1660–5. 10.1111/j.1532-5415.2009.02393.x
    1. Creditor MC. Hazards of hospitalization of the elderly. Ann Intern Med. 1993;118(3):219–23. 10.7326/0003-4819-118-3-199302010-00011
    1. Canadian Institute for Health Information. All-Cause Readmission to Acute Care and Return to the Emergency Department (Ottawa, Ont.: CIHI, 2012).
    1. Deiner S, Westlake B, Dutton RP. Patterns of surgical care and complications in elderly adults. J Am Geriatr Soc. 2014;62(5):829–35. 10.1111/jgs.12794
    1. Canadian Institute for Health Information. Hospital Morbidity Database (Ottawa, Ont.: CIHI, 2012–2013) Available from:
    1. Khadaroo RG, Padwal RS, Wagg AS, Clement F, Warkentin LM, Holroyd-Leduc J. Optimizing senior’s surgical care—Elder-friendly Approaches to the Surgical Environment (EASE) study: rationale and objectives. BMC Health Serv Res. 2015;15:338 10.1186/s12913-015-1001-2
    1. Liu B, Almaawiy U, Moore JE, Chan W-H, Straus SE. Evaluation of a multisite educational intervention to improve mobilization of older patients in hospital: protocol for mobilization of vulnerable elders in Ontario (MOVE ON). Implement Sci. 2013;8(1):76 10.1186/1748-5908-8-76
    1. Rolfson DB, Majumdar SR, Tsuyuki RT, Tahir A, Rockwood K. Validity and reliability of the Edmonton Frail Scale. Age Ageing. 2006;35(5):526–9. 10.1093/ageing/afl041
    1. Podsiadlo D, Richardson S. The timed “Up & Go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39(2):142–8. 10.1111/j.1532-5415.1991.tb01616.x
    1. EurolQol Group. EQ-5D: A standardized instrument for use as a measure of health outcomes [EurolQol web site]. 1990. Available at: http://. Accessed March 27, 2017.
    1. . The SF-12(r): an even shorter health survey [Optum web site]. 1996. Available at . Accessed March 27, 2017.
    1. Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ. 2005;173(5):489–95. 10.1503/cmaj.050051
    1. Shumway-Cook A, Brauer S, Woollacott M. Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go Test. Phys Ther. 2000;80(9):896–903.
    1. Luo N, Johnson JA, Coons SJ. Using instrument-defined health state transitions to estimate minimally important differences for four preference-based health-related quality of life instruments. Med Care. 2010;48(4):365–71. 10.1097/mlr.0b013e3181c162a2
    1. Wyrwich KW, Tierney WM, Babu AN, Kroenke K, Wolinsky FD. A comparison of clinically important differences in health-related quality of life for patients with chronic lung disease, asthma, or heart disease. Heal Serv Res. 2005;40(2):577–91. 10.1111/j.1475-6773.2005.00373.x
    1. Johnson J, Pickard AS. Comparison of the EQ-5D and SF-12 health surveys in a general population survey in Alberta, Canada. Med Care. 2000;38(1):115–21. 10.1097/00005650-200001000-00013
    1. Hopman WM, Towheed T, Anastassiades T, Tenenhouse A, Poliquin S, Berger C, et al. Canadian normative data for the SF-36 health survey. Canadian Multicentre Osteoporosis Study Research Group. CMAJ. 2000;163(3):265–71.
    1. Vanderweele TJ, Knol MJ. A Tutorial on Interaction. Epidemiol Methods. 2014;3(1):33–72. 10.1515/em-2013-0005
    1. Li Y, Pederson J, Churchill T, Wagg A, Holroyd-Leduc J, Alagiakrishnan K, et al. Impact of frailty on outcomes after discharge in older surgical patients: a prospective cohort study. CMAJ. 2018;February 2(190):E184–90. 10.1503/cmaj.161403
    1. Siu AL, Penrod JD, Boockvar KS, Koval K, Strauss E, Morrison RS. Early Ambulation After Hip Fracture: effects on function and mortality. Arch Intern Med. 2006;166(7):766–71. 10.1001/archinte.166.7.766
    1. van der Leeden M, Huijsmans R, Geleijn E, de Lange-de Klerk ESM, Dekker J, Bonjer HJ, et al. Early enforced mobilisation following surgery for gastrointestinal cancer: Feasibility and outcomes. Physiotherapy. 2016;102(1):103–10. 10.1016/j.physio.2015.03.3722
    1. Schaller SJ, Anstey M, Blobner M, Edrich T, Grabitz SD, Gradwohl-Matis I, et al. Early, goal-directed mobilisation in the surgical intensive care unit: a randomised controlled trial. Lancet. 2016;(10052):1377–88. 10.1016/S0140-6736(16)31637-3
    1. Krumholz HM. Post-Hospital Syndrome—An Acquired, Transient Condition of Generalized Risk. N Engl J Med. 2013. January 10;368(2):100–2. 10.1056/NEJMp1212324

Source: PubMed

Sponsoren und Mitarbeiter

Krankheiten

Drogeninterventionen

3
Abonnieren