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‘We must formally acknowledge patient deconditioning as harm’


Ann-Marie Riley praises the #endPJparalysis campaign, stressing how quickly loss of muscle strength can happen in hospital and how important it is to keep patients mobile

The #EndPJparalysis campaign, which started with a few tweets in November 2016, has now been shared both nationally and internationally, and impressions on Twitter have reached almost 170 million.

Some argue that getting patients up, dressed and moving is just what nurses have done for years and I agree to some degree. However, evidence suggests that many patients spend up to 83% of their time in bed, with even those who are more than able to walk in hospital hardly doing any steps.

Loss of muscle strength can begin frighteningly quickly – within hours in some cases. For a person who, before admission, was just managing to stand from a chair or get on and off the toilet, even a small amount of muscle strength loss can be life-changing. I wonder how many nursing staff receive training on preventing deconditioning either pre- or post-registration?

Evidence suggests that, compared with those who are not admitted to hospital, hospitalised older adults are significantly more likely to develop some disability in terms of activities of daily living (ADLs). We have to ask: why? Are we satisfied that we collate the right information about how patients managed these activities at home so we can plan to maintain as much of that ability as possible? Do we investigate loss of ability and the root cause of why it happens in hospital?

At Nottingham University Hospital (NUH) we will soon be capturing loss of ADLs via incident reporting and new electronic nursing documentation. Although our data capture and evaluation methods are likely to require refinement over time, we will at least be formally acknowledging deconditioning as harm and striving to determine root causes. Fear of patients falling, inadequate staffing levels and lack of time to focus on mobilising patients are common themes that have arisen from the many presentations we have done across the country. I believe a formal process to recognise deconditioning harm is needed across all care settings so we can begin to have honest conversations about why deconditioning happens.

A national challenge to capture one million patient days of getting patients up, dressed and moving is running until 26 June. An app will support data capture. Even if you are not able to submit data, what you can do is ask a simple question – why? Immobility can be lifechanging so why is this person not getting out of bed and moving? Changes to continence function can be lifechanging so why is this person not going to the toilet instead of using aids?

I’m proud of our team at NUH who are asking these types of questions and developing local solutions to improve care delivery and prevent harm from deconditioning. For example, one of our trauma and orthopaedic wards has seen reductions of 37% in falls, 80% in complaints and 86% in pressure ulcers through the implementation of a simple bundle of initiatives (see next month’s issue).

Imagine the potential reduction in harm if we could replicate even a fraction of this nurse-led improvement across multiple healthcare settings.

Ann-Marie Riley is deputy chief nurse (strategy) at Nottingham University Hospitals Trust.

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Readers' comments (8)

  • I was an inpatient for 2 weeks following a car accident on an acute orthopaedic ward. The #EndPJparalysis is a step in the right direction. However, getting a patient dressed into their own clothes and then sat in a chair for the rest of the day is not going to end muscle wastage. I would imagine it would increase the risk of pressure sores. Just as a by the by, my mother was admitted with complete heart failure and was expected to die, being "a survivor" her words not mine, she defied the odds. After having a triple wired pacemaker inserted and recovering on the cardiac ward for a fortnight in good health, she was then transferred to the elderly care ward for a fortnight to "prepare" for her discharge. Within a week she had developed a pressure sore from being left in a chair all day on a wrinkly inco pad (she was in no way incontinent prior to admission and indeed once home wasn't either- can't be bothered to take her to the loo I think) I was furious. What made it doubly worse was that this was the hospital I worked in at the time.
    To get back to the point, the only time these lovely ladies get any exercise is when the physio come and take them for a walk, once a day if their lucky. There are simply not enough staff to support. They are constantly run off their feet and there is such a pressure on the beds that the coordinators just want to move patients on to the next stage. At least they might get more rehab then, but sadly the rot has already set in.
    I spent a week next to a delightful 90 year old lady who lives on her own but has a very supportive family who live very close by. I felt so protective of her. I shall go into more detail in a later article but frustrated beyond belief. Just out into a chair all day, she was clearly uncomfortable in that one position. I was encouraged to sit in a chair, I have two fractured legs and a fractured right arm, but at least in bed I could move around and change position. I also religiously did exercises to maintain muscle strength. In a chair, I would get a numb bum very quickly and would be desperate to get back into bed where I could lie on my side.

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  • Was quite happy to post as me but it wouldn't let me!

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  • I support the campaign as a nurse and as a recent inpatient. As a nurse who has cared for older people for decades I can say that encouraging and enabling people to retain and regain mobility doesn't need more staff. Having more able patients actually reduces nursing workload. Its all about culture.
    The PJ paralysis is also about culture change. I recently had surgery and as soon as I came round and drank enough to convince the nurses to discontinue my IV fluids I got up. My nurse accompanied me to the toilet, having checked my blood pressure first, as I was feeling a bit wobbly. I then changed into my nightclothes. In the morning I got up and dressed and went for a walk on the ward. I felt so much better up and dressed but I was the only one on the ward who was dressed. In getting dressed I put yesterday and the surgery and the problems I'd had behind me and started my recovery. We need to change the culture on wards so that people who are recovering don't lie around getting deconditioned .

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  • When we add to the in-patient cocktail dementia, multiple pathologies of old age and polypharmacy, we create the perfect tsunami for failing our patients
    I support and endorse the statement that active deconditioning constitutes harm

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  • Retired from nursing a few years ago after 35 years, and find it depressing to see an idea like getting people moving, to reduce muscle wastage, come around as if it were a new discovery. I knew this when I was nursing older people 30 years ago. I'm sure Linda Nazarko did as well. How much more wisdom has my quondam profession lost?
    I too have personal experience of this. Last Summer I was hospitalised for three weeks with unstable angina, just waiting my turn for treatment on an acute ward. Of necessity my activity was severely limited, and I was aware of how rapidly I was losing muscle mass and stamina. It took me the rest of 2017 to regain it, and I am relatively fit and well motivated. If I had been ten years older I might have struggled to get my mobility back.
    And no, sitting people in chairs, which I saw during my stay, is not the answer, is it? I calculated that my stay in hospital, including blue light admission but excluding actual treatment, cost about £13,000. It could have been much more if I had need rehab. Money spent on therapy to keep people moving will be more than repaid by freeing up an expensive bed

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  • It isn't just older people . My 21 year old son had AML and was in hospital for 6 weeks in isolation after diagnosis . He lost condition rapidly due to metabolic fever and rubbish food. This was a young man who lived for sport and fitness and had just qualified as a personal trainer as he presented with the signs of leukaemia .As a family we would go in and accompany him on walks around the hospital and the gardens if the weather was fine . We pressed for better food to try and improve his calorie intake and all he was offered was unpalatable fortisip . He should have been offered the staff menu after 2 weeks stay ( the patient menu only has a one week cycle) but we were not told of this option so we were taking him to the staff restaurant at lunchtime where the food was hot and better presented . We were asked not to bring in ready meals to heat on the ward for health and safety reasons but I was told I could bring food from home . I have no idea how I was supposed to keep it hot on a 10 mile journey. I did try and bring high calorie smoothies and cakes etc but he hasn't ever been a big cake or biscuit eater . I was worried about his loss of muscle (10kgs in 6 weeks )and it was all muscle as he had little fat to lose so I asked if physio would see him. I was told as he could walk around his bedspace ( he wasn't allowed out of his room unless accompanied) and as the ward average age was 80 so all that was the capability expected then he wouldn't have any input by physiotherapy . . No consideration was given for his youth and the PJ paralysis that occurred .He was weighed everyday but that didn't seem to have any influence on his care although his loss of condition was recognised nobody except his family attempted to do anything about it .Fortunately I managed to persuade him he would be better off having his subsequent treatment in a regional Teenage and Young Adult centre and it was night and day in terms of care tailored to his age and holistic care . I haven't worked in hospitals for a very long time but I was shocked that there was no appraisal of his starting condition and no efforts to try and ameliorate his rapid loss of condition . He is now 2 years down the line from the diagnosis and has yet to restore his pre-diagnosis condition . The medical care was good but the holistic care by the wider health care team was sadly lacking .

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  • Mobility on a hospital ward is a joke, you either sit in a very uncomfortable chair by your bed, or sit in bed.
    If you wander the ward to stretch your legs, nurses tell you you are encroaching on other folks space.
    Where do patients go for a bit of exercise as we no longer have days rooms?
    Why can't all wards have a small exercise room, a treadmill, some weights, surely too much to ask for.
    Whilst i enjoy a bit of activity, physio's come in and start bossing folk around, it is their attitude I really object to, far too bossy and dictatorial thinking they can maul us as and when they want and treat us like we are stupid.

    I had one male physio who though he had the right to put his hands / arms all over me, not even asking for my consent ... and I told him where to get off. Being unwell doesn't mean we are stupid or 'lost our marbles' or want some old bloke mauling us..
    a rehab class allowed patients to bring their families in to observe, do i really want treatment with an audience ... no i don't!
    What happened to the patients dignity and self respect as some of these observers may in fact be our neighbours.

    Make the correct facilities available outside of the hospital for 'outpatients' and at ward level for in-pateints, I am sure many patients would love the opportunity to get away from the bedside and have a bit of fun in a small gym, a social chat and a change of environment.

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