In 1960, the U.S. Public Health Service reported that disability from immobilization was one of 10 preventable health problems and that such disability could be reduced by 50-75 percent. Decades later, immobility is still an issue and garnering even more attention in the era of healthcare reform, reimbursement, and patient-centered care.

Just this past May, The New York Times covered a presentation at the American Geriatrics Society’s annual scientific meeting in Texas, where Dr. Cynthia Brown of the University of Alabama at Birmingham School of Medicine and the Birmingham Veterans Affairs’ Fall Prevention and Mobility Clinic discussed a 2009 study she conducted at a Veterans Affairs hospital. She and her colleagues found that while healthy older adults are on their feet more than six hours a day at home, hospitalized patients in the study spent 83 percent of their time in bed. In this study, a group of patients encouraged to get up and do as much as they could each day showed virtually no change in their life-space score one month after they had been discharged (another measure of being able to perform day-to-day activities), but those who didn’t walk experienced a significant drop in this score.

Architects and designers can be part of the mobility solution. Like so many adverse events in healthcare, the hospital environment contributes to this outcome.

Putting it in context
Most hospitalized older adults spend the majority of time in bed, and even short periods of bed rest accelerate muscle degeneration and deconditioning. However, the downstream effect is even more sobering. Dr. Kenneth Covinsky and his colleagues at the Department of Medicine and Division of Geriatrics at the University of California, San Francisco reported in a 2011 paper that at least 30 percent of medically ill hospitalized patients over 70 years old are discharged with a new disability that wasn’t present before the onset of illness. In fact, the authors cite a study indicating half of disability cases among older adults occurs in the setting of medical hospitalization. In another 2011 paper,  Dr. Walter Ettinger, who was with the University of Massachusetts Medical School and the UMass Memorial Medical Center at the time of the study,  states that these hospital-acquired conditions often result in weeks of rehabilitation (if they’re not permanent) with an inability to perform “activities of daily living,” like bathing or dressing.  Even more frightening is a 2008 study by Dr. Cynthia M. Boyd of Johns Hopkins University School of Medicine and the Johns Hopkins Bloomberg School of Public Health and colleagues, where 41 percent of those affected by hospital disability died within one year.

These types of immobility studies have been underway for years, and results indicate that even small changes make a difference. A study conducted by Steve Fisher of the Division of Rehabilitation Sciences at the University of Texas Medical Branch and colleagues in 2010 found that patients who increased their walking by at least 600 steps from the first to second 24-hour day  were discharged approximately two days earlier than those who didn’t.

Two themes are evident from the literature: the negative aspect of the bed and the positive nature of activity. “The effects of immobility are insidious,” says Roger Leib, a member of the FGI Health Guidelines Revision Committee (HGRC). “There’s no acute trauma, like a fall. No acute onset, like a hospital-acquired ‘superbug.’ So immobility remains underrecognized as perhaps the most common, debilitating, and systemically expensive unintended outcome in healthcare today.”

If the design of a patient room is considered, the focus is mostly on the bed, for many reasons. However, this focus can result in a preoccupation of making sure everything can be done from the bed, with no incentive for the patient to move and perhaps even a disincentive to leave the bed.

Getting out of a hospital bed can be intimidating to an older person who is sick, in pain, afraid of falling, and who’s been warned by the nurse to call for assistance. But fear exists for nurses and hospital administration, as well. A fall resulting in an injury is part of the group of adverse events that are no longer reimbursed by Medicare. Additionally, the CMS Partnership for Patients has included immobility with falls as a specific targeted improvement area. (Studies have found that fall-related injury has the highest likelihood of developing new or worsening disability.) The design of the environment can be an underlying condition that contributes to immobility, and this will be one of the components of the new required safety risk assessment in the 2014 FGI Guidelines for Design and Construction of Hospitals and Outpatient Facilities. With information on this topic (as it relates to facility design) still emerging, the solutions related to the built environment are often based on expert opinion drawn from investigators conducting clinical studies on other outcomes.

Where opportunity lies
There are several considerations for design. First, the hospital environment is often designed for the caregiver rather than the patient. A balance is needed to ensure patient safety and comfort, as well as the safety and efficiency of staff (patient handling) in their workspace. Second, design elements can either contribute to the patient not walking because of fear of falling or facilitate patient mobilization. According to Mary Matz, national patient care ergonomics program manager for the VA, patient handling and mobilization-assistive devices along with the appropriate sling support patients so they can move without that fear. Lastly, the combination of acute illness and uncomfortable environments can lead to or worsen depression, compounding functional decline.

There’s a need for research that more specifically addresses this topic. For example:
•    Longer term prospective studies on the impact of hospitalization in different types of environments
•    Studies to identify whether family presence and engagement have an impact on mobility as a patient outcome
•    Research that considers the combination of falls and patient handling policies and equipment use, as the two areas are integrally linked
•    Whether the use of overhead patient lifting devices with repositioning slings decreases hospital-acquired pressure ulcers, pneumonia, or length of stay
•    Whether the use of overhead patient lifting devices with ambulation slings result in more rapid rehabilitation and/or a decrease in length of stay
•    Evaluations to determine the optimum space within a patient room for safely performing patient care at the bedside, moving patients, and transferring patients with lifting devices.

Renovations can be an interesting testing ground, as well. Teams might consider the impact of furniture types and use, as well as minor changes to hallway design (such as distance markers, space for chairs, etc.).

In a 2012 interview with Healthcare Design, Derek Parker, the 2012 Center for Health Design Changemaker Award recipient, bemoaned the lack of innovation happening in healthcare today. Combatting some of the status quo thinking, he said, “We’re designing now a series of devices that makes it easy and safe to get patients out of bed, and a device that supports them for early mobility. We’re designing the corridors in such a way that there's a traffic lane, where people can actually be walking, and graphics that allow them to measure their progress day by day: ‘I made it to the poppies yesterday, so I'm going to make it to the apples today,’ for example.”

Architects and designers have the opportunity to be on the leading edge of this issue, helping healthcare providers understand how the environment can part of a set of tools to improve the plethora of outcomes that result from immobility.

Ellen Taylor, AIA, MBA, EDAC is director of Pebble Projects at The Center for Health Design in Concord, Calif. She is a member of the 2014 Health Guidelines Revision Committee and can be reached at etaylor@healthdesign.org. Special thanks to Roger Leib, AIA, ACHA, founder of ADD Specialized Seating Technology and principal, Develop, LLC, and Mary W. Matz, MSPH, CPE, CSPHP, national patient care ergonomics program manager for the VA, Office of Public Health, Occupational Health Group, who contributed research ideas and shared their professional experiences for the article content.