The Importance of Maintaining Mobility during Hospitalization

Karine Shnorhokian

Improving Mobility for the Hospitalized Patient

Walden University

NURS 6052-Section 7, Essentials of Evidence-Based Practice

April 27, 2016

Summary

Patient immobility during a hospitalization is linked to deconditioning, bed sores, longer hospital length of stay (LOS), and an increased risk of hospital-associated pneumonia (HAP) (Czapluski, Marshburn, Hobbs, Bankard, and Bennett, 2014; Stolbrink et al.2013).  Barriers to mobilize patients during an acute admission include lack of assistive devices, fear of patient falling, and lack of motivation amongst both the staff and patients (Czapluski, et al., 2014).  Zisberg, Shadmi, Gur-Yaish, Tonkikh, and Sinoff (2015) contribute hospital-associated function decline due to lack of immobility both immediately and 30 days post hospitalization.  Brown, Friedkin, and Inouye (2004) found adverse outcomes are related to lack of ambulation during hospitalizations, which contributes towards a higher incidence of skilled nursing facility (SNF) placement and higher hospital LOS. 

Initiatives involving supervised walking programs during hospitalizations reduce the need for post-acute care in the SNFs as well as reduce LOS and overall cost reduction (Hastings, Foot injurySloane, Morey, Pavon, & Hoenig, 2014).  A systematic search through the Cochrane Collaboration on immobility and hospitalization conclude a greater discharge of patients to home for those that are ambulated during their hospitalization resulting in a decrease of post-discharge complications (De Morton, Keating, & Jeffs, 2009).  Initiatives to improve mobility help to reduce health care spending, resulting in over $900 in savings per Medicare beneficiary (Ghimire et al., 2015). 

There is substantial evidence to support targeted mobility initiatives during a patient’s hospitalization to reduce the risk of deconditioning that occurs.  Staff engagement in these targeted initiatives must support such findings to empower healthcare providers to implement mobility based projects for hospitalized patients. Using evidence-based practices (EBP) to identify opportunities for change in the clinical practice help advance nursing leadership and improve patient outcomes.

Early Ambulation during Hospitalizations

Hospitalizations are necessary for our general patient population to treat acute or chronic illnesses and improve mortality rates related to these diseases.  During an acute hospitalization, patient ambulation is often overlooked due to the acute illness.  A patient’s functional status post-discharge is directly related to their mobility during a hospitalization, and with approximately 50% to 70% of hospitalized patients only ambulating within their room during a hospitalization, patients are at greater risk for functional decline (Zisberg, Shadmi, Gur-Yaish, Tonkikh, & Sinoff, 2015).  Lack of mobility during a hospitalization can lead to an increased length of stay, decreases the quality of life, and result in suboptimal care (Czapluski, Marshburn, Hobbs, Bankard, & Bennett, 2014).  The purpose of this project is to identify an issue in nursing practice such as ambulation during a hospitalization, conduct a literature review, and translate evidence into practice from conclusions drawn from the literature review.

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Identifying a Research Problem

The Centers for Medicare & Medicaid Services (CMS) are initiating several innovative programs to improve care coordination to reduce healthcare spending and improve quality of care (Kovner & Knickman, 2011).  Accountable care organizations (ACOs) are emerging in hospitals throughout the country and responsibility to manage costs across the continuum involve close monitoring of patients discharged to skilled nursing facilities (SNFs) and utilization of other ancillary services.  Mobilization programs targeted for an at-risk population for both inpatient and outpatient is estimated to save on average $938 per Medicare beneficiary (Ghimire et al., 2015).  Though rehabilitation is warranted to improve functionality status, there is a presumption that lack of mobility during hospitalizations account for multiple SNF discharges resulting in increased healthcare spending.  It is encouraged for nurses to use evidence-based practice (EBP) by conducting literature searches to find the most reliable data supporting early hospital ambulation for patients.  The result is better patient care and an increase of patients going home post discharge.

Relevant Questions Evaluated for Use

Identifying that decreased mobility during a hospitalization increases healthcare spending and worsens overall patient outcomes, questions need to be formulated in order to evaluate the efficacy and feasibility of this issue. Polit and Beck (2012) define feasibility as addressing realistic concerns related to accessibility of staff, information, external factors, and overall cooperation in undertaking such a project. The five questions developed to evaluate and review this process are listed below.

Question 1: Do patients with a bedrest order have a longer length of stay (LOS) in the hospital compared to patients who have activity orders?

The process of data gathering and evaluation will be retroactive for this study.  Data and accessibility of the electronic health record (EHR) would assist in gathering this information.  Working with the hospital’s performance improvement (PI) team, we would gather data on two selected nursing units with high census levels and considered to have a geriatric population.  The following data request would include medical record number, date of admission, date of discharge, activity order including specific comments, and diagnosis.  Each floor would be separated into two groups; patients with activity orders and patients on bedrest.  Their LOS would then be compared to determine if there is a notable difference.  Since our healthcare organization has a homegrown EHR, gathering this type of specific data is readily available.  It would require a small team from PI and the clinical team to analyze and tease out the data and determine any significant outliers that may need to be winsorized to generate a conclusion.  The cost would not be a factor considering this is a retrospective analysis.  There also would be no ethical concerns due to the nature of not forcing currently admitted patients to remain on bedrest.      

Question 2: Does patient mobility during hospitalizations correlate to a patient’s ability to be discharged home versus a skilled nursing facility (SNF)?

This study would need to be conducted over a two quarter cycle.  Two floors would pilot the program, and it would involve education and an interdisciplinary approach to engage and execute. Two separate study groups would be required on each floor, involving one group on a mobility program, and one group that is part of the current activity order process.  Since study is taking place on a high census inpatient nursing unit, there are readily available participants.

Additional resources may need to be considered such as a mobility technician, which would incur costs, additional documentation for the clinical team, which may affect direct patient care, as well as the need to purchase pedometers to adequately capture ambulation distances.   Additional materials like pedometers will involve education on how to use the device and when and where this information would be documented in a consistent manner.  Our EHR is able to capture discharge dispositions to track home versus SNF encounters.  Ethical concerns for this study are not concerning due to the fact that we are still utilizing the current patient activity order process for those patients not part of the mobility program.    

Question 3: Does utilization of a pedometer to track ambulation with specific patient-centered goals improve a patient’s motivation to ambulate during a hospitalization?

This study can be conducted using similar methods as the study in question number two.  Patients on the mobility program are given an ambulation goal determined by the physical therapy team and encouraged to ambulate throughout the day to meet that goal.  Feasibility concerns involve staffing on the nursing units for those patients who continuously request and need assistance to ambulate.  This activity may disturb the current workflow for patient care technicians and other staff members involved in other patient’s care.  Ethical concerns involve patient safety and if engaging patients to get out of bed and ambulate when it may not be appropriate need to be considered.

Adherence to specific criteria for patients on the mobility program and education to patients and their families will need to be directed and re-directed each shift. Cost would incur by purchasing of the pedometers and the assumption that the patient has the option to take it home with them as well as the need for additional staff to help with patient ambulation.

Question 4: Does ambulation during hospitalizations cause a patient to be at risk for falls or decrease fall risk?

This study would entail a two-step process of reflecting on prior data as well as current data.  Initially, retroactive falls data would need to be obtained and reviewed to evaluate patient’s activity orders and physical therapy ambulation orders.  Similar to study one, the data would review fall documentation for two nursing units.  Considerations for other factors causing falls like medication, disorientation, and other instabilities would need to be taken into account.  Once preliminary data is obtained, we then can evaluate the process similar to study number two.  The study would take place over two quarters. 

Nursing staff will continue to chart Morse Fall Scale on each patient, and identify and classify any patient that is a moderate to high fall risk.  Patients on the mobility program will be educated if they are a high fall risk and continue to receive a yellow armband indicating they are at risk for falls. No additional costs would incur for this particular study.  Most costs are tied to study number two.  Ethical concerns would include if there is a higher incidence of falls for patients on the mobility program it may result in stopping the study. 

Question 5: Does ambulation decrease the risk of developing hospital acquired pneumonia (HAP) versus patients who are not ambulatory? 

This particular study would also take place over two quarters.  Both study groups would be closely monitored for signs and symptoms of HAP.  Certain patient populations such as those who had recent surgery or already diagnosed with pneumonia would be excluded from the study.  All others would follow a similar process in study two, and in addition monitor for signs and symptoms in the non-ambulatory group. 

The HAP diagnosis would result in consolidation or infiltrates in the lungs greater than 48 hours of an admission as well as other presentable clinical features.  The feasibility of the study may be limited due to additional patient conditions and external factors related to the admission.  Costs may incur due to patients going for additional radiological studies.  There also may be conflicting diagnoses agreement amongst physicians treating the patient.

Lack of mobility for patients during hospitalizations occurs in hospitals throughout the country.  Nurses who work in hospitals are engaged in the moment and are disconnected with the feasibilities and realities for patients beyond their acute hospitalization. Unaware of the direct effects ambulation has on a patient’s discharge disposition, there is little eagerness to ambulate patients. Conducting literature searches to find evidence-based practice in support of the benefits of ambulation will help engage nursing staff to be more proactive for their patients.  The support generated from these five questions help to formulate a relevant PICOT question that will further be analyzed to determine if its significance supports EBP.    

PICOT Question

The PICOT framework allows for evidence-based practice questions to be well phrased in order to help dissect this question into searchable words (David, 2011). The acronym PICOT stands for patient or problem (P), intervention (I), comparison (C), outcome (O), and time (T). 

After an analysis of all the different formulated questions and reviewing their feasibility, the following PICOT question was developed: In patients admitted to the hospital, do patients on early mobility programs decrease their LOS and result in less SNF discharges compared to those patients who are not on a mobility program?  In teasing out the specifics for this question, the population (P) accounts for patients admitted to the hospital.  The intervention (I) involves patients being placed on an early mobility program. 

The comparison (C) is those who are on a mobility program versus those who have standard activity orders.  The outcome will examine LOS and patients going home versus going to a SNF.  The timeframe is having patients placed on a mobility program within 24 hours of their admission and have ambulation goals throughout their hospitalization.

Ten Keywords for Literature Searches

Ten keywords that will be used for this search include hospitalization, patient ambulation, mobility, length of stay, hospital acquired pneumonia, skilled nursing facilities, patient deconditioning, mobility programs, patient engagement, and fall-risk.  Using CINAHL Plus with Full Text, I searched patient ambulation and LOS. This search yielded 3 results, with one article discussing outcomes of hospital acquired pneumonia (HAP) for patient’s part of a mobility bundle (Stolbrink et al., 2013).  The study did fail to find improvements in LOS or reduction in falls.  An additional search of hospitalization, mobility, and skilled nursing facility yielded five results, including an article focusing on mobility program interventions which significantly improved patient outcomes and reduced spending (Hastings, Sloane, Morey, Pavon, & Hoenig, 2014).  Adjusting keyword by specificity helped to find more relevant and appropriate articles related to the developed PICOT question on this topic. 

Literature Review on Hospital Mobility

The literature review conducted is to support the PICOT question: In patients admitted to the hospital, do patients on early mobility programs decrease their LOS and result in fewer SNF discharges compared to those patients who are not on a mobility program?”  Both filtered and unfiltered searches were performed using identified keywords and included CINAHL Plus and Cochrane Database of Systemic Reviews databases.  These searches can help to determine if stated PICOT question is validated through literature review and synthesis. 

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Prospective Studies on Functional Decline

Two prospective cohort studies have found that patients who are hospitalized not only face functional decline but adverse outcomes due to limited mobility or bedrest (Zisberg et al., 2015; Brown, Friedkin, & Inouye, 2004).  According to Zisberg, et al. (2015), multiple modifiable risk factors including low mobility during a hospitalization accounts for functional decline both immediately and 30 days post discharge.  Of the 684 participants aged 70 and older measured in this study, 282 participants (41.2%) reported a functional decline at discharge and 317 (46.3%) one month after discharge.  Some factors including continence care, nutritional intake, and mobility affected these outcomes. fit 55

This study is perceived to be more of an exploratory prospective study, due to the measurement of probable causes related to low functionality decline (Polit & Beck, 2012).  Though mobility is referenced in this article, this study does not support the PICOT question referenced in this paper reflecting the correlation between mobility and length of stay (LOS) or reduction in skilled nursing facility (SNF) discharges.

Brown, Friedkin, and Inouye (2004) found low mobility results in adverse outcomes supporting the PICOT question.  In this study, 498 hospitalized medical patients aged 70 and older were given a mobility level score with weighted levels of low (80 patients), intermediate (157 patients), and high (261 patients).  Of the 434 patients who survived the hospitalization, 13% resulted in a discharge to a skilled nursing facility, including 31% of those reported of having low mobility. 

Limitations of the study include the basis for determining low mobility scores for patients with severe illnesses, as well as mobility scores assessed by observational nursing documentation.  The study is valuable, but upon further review, data collection occurred from 1989 to 1991.  The basis of including this review was to analyze it against another prospective cohort study to determine consistencies with the methodologies between both studies

Incidence of Immobility and Adverse Outcomes 

Stolbrink et al., (2013) involved a cluster design method evaluating the efficacy of patients on an “Early Mobility Bundle” compared to a control group to determine the incidence of hospital-acquired pneumonia (HAP) and effects on length of stay.  Within the intervention group of 678 patients, there was a remarkably higher activity count compared to the control group of 501 patients.   The increase in activity demonstrated a lower incidence of HAP within the intervention group of 3.6 % compared to the control group which was 10 %.   The limitations of the study come from the design itself with factors like adequate matching and sociodemographics of the two wards where the data was being collected.  In a review of the data, a suggestion of larger randomized studies is suggested to determine if there is significance in mobilizing patient to prevent HAP.  The length of stay measurement of this study was unable to conclude LOS was lower in the intervention group, therefore, results in uncertainty if mobility affects LOS.

Targeted Ambulation Programs

According to Hastings et al. (2014), evidence suggested that early ambulation during hospitalizations reduces the likelihood of a patient being discharged to a skilled nursing facility (SNF).  This nonequivalent control group design aimed to place patients on a targeted mobility program (92 patients) comparing them to patients who received the general standard of care (35 patients).  The results of this study showed that 92 % of those on the mobility intervention went home compared to only 74% in the non-intervention program.  LOS, however, was not statistically significant. 

Given the study was not blinded, it could be inferred that the limitations of the study suggest that there was more of a concerted effort to discharge patients to home who were part of the mobility initiative.  Compared to a study by Padula, Hughes, and Baumhover (2009) reviewed in the course readings, this too was a nonequivalent control group design.  The results suggest a significantly lower LOS in the intervention group by 3.76 days.  One notable difference in the Padula et al. study discloses that this was a nurse-driven mobility program compared to Hastings et al., which used a therapy assistant.  Other limitations of these studies should not be ruled out in determining true validity in LOS reference.

The weaknesses of these studies are related both to the study sizes as well as the limitations of the design setup.  The study by Strolbrink et al., further disclose that age is associated with HAP risk.  The control population average age was 81, and the intervention age was 75.  If age was a concerning factor, the two studies should have capped the age of the participants.  Hastings et al. did not have a significant enough control population to compare to those in the intervention program.      

Literature Review of a Systematic Search

Literature reviews in the context of systematic reviews are critical when making important policy decisions resulting in practice changes (Houde, 2009).  The feasibility in devoting resources, education, and cultural buy-in for mobility targeted programs must be analyzed through systematic review to avoid biased results and determine plausible outcomes.

Filtered review on mobility.

De Morton, Keating, and Jeffs (2009) conducted a systematic review concluding that targeted multidisciplinary interventions on mobility for hospitalized patients result in an increase of patients discharged to home, as well as a reduction in LOS and cost for hospitalized older patients. The inclusion data for this study, at least, one measure of function or hospital outcome needed to be reported.  Over 3,138 potentially relevant papers were obtained screening their titles and abstracts, resulting in 143 papers obtained in full text for further review.  A predetermined criterion was applied resulting in nine trials included in the examination.  The results of this study were evaluated for bias and recommend further trials needed to explore what type of exercise program is most advantageous to determine if exercise alone versus other multidisciplinary interventions is most beneficial.     

Hospital

Preliminary Conclusion

Following this literature review, there is evidence suggesting that increased mobility results in a decreased LOS and reduced discharge to a SNF.  It is not yet clear however which program or exercise intervention will make the biggest impact.  Though nurses tend to favor EBP and respect its application to their everyday practice, institution barriers may still exist resulting in implementation difficulties (Majid et al., 2011).  Given the research has yet to identify the gold standard on hospital mobility and what exactly what type of mobility program needs to be executed, this suggested PICOT question should not be entirely excluded when it comes to implementing a practice change.  Further research should review targeted mobility programs and suggested implementation process.

Translating Evidence into Practice

Restatement of PICOT Question and Nursing Significance

Evidence-based research to validate the PICOT question: In patients admitted to the hospital, do patients on early mobility programs decrease their LOS and result in fewer SNF discharges compared to those patients who are not on a mobility program? is supported by literature review and data analysis.  Formulating a PICOT question that reflects the need for true practice change through (EBP) gives organizational leadership and stakeholders the tools needed to implement new protocols.  Mobility is significant to nursing practice due to the adverse effects lack of ambulation causes both immediately and 30 days post-hospitalization.  By incorporating evidence to initiate practice change with regards to mobility not only will it improve patient outcomes and overall quality but also reduce healthcare costs.

The clinical relevance of this PICOT question aligns with triggers or reasons for a practice change.  Many evidence-based models focus on two trigger models: problem-focused and knowledge-focused (Polit & Beck, 2012).    Problem-focused triggers are identified through measuring retrospective suboptimal outcomes with regards to the hypothesis outlined in the PICOT question. Knowledge-focused triggers are identified through literature reviews on multi-hierarchical levels to determine the relevance, bias, and EBP supporting the change.  Polit and Beck (2012) draw upon these trigger models within organizations help prioritize the significance of the research question.   

Summary of Literature Findings

The literature review conducted for this selected research problem consistently identifies hospital immobility is directly related to negative patient outcomes (Zisberg et al., 2015).  Along with overall deconditioning, research correlates findings that result in higher hospital LOS as well and an increased discharge to SNFs.  Hastings et al. (2014) conclude findings supporting a higher percentage of patients going home versus skilled nursing facilities (SNF) for those who are placed on a targeted mobility program.   

The study supports the need for mobility to be an interdisciplinary approach but involves dedicated staff members who are committed to ambulating patients regularly.  The study by Zisberg et al. (2015) found that limited mobility during a hospitalization resulted in 41.2% of participants reporting a functional decline post discharge.  Modifiable risk factors need to be assessed to account for practice change within an organization.  Through identifying the implications posed by immobility in the hospital and the statistical relevance on how these negative outcomes directly affect the patient, nurses can further engage in decision-making changes through clinical-based scenarios. 

Evidence-Based Practice and Better Outcomes

Evidence-based practice in the clinical setting results in the best patient outcomes (Polit & Beck, 2012).  There is a consensus that outcomes from rigorous research projects provide strong evidence in support of practice change.  Failure for organizations, especially nurses to not comply with implementing change through EBP can result in poor patient outcomes and high mortality rates.  It is reported that 65% of patients experience a decline during their hospitalization, with most patients failing to improve by discharge (Brown, Friedkin, & Inouye, 2004). 

In addition to this, it is estimated those with loss of functional decline are at risk for falls post discharge and may account for up to 15% of readmissions (Hastings et al., 2014).  Patients placed on early mobility programs demonstrate maintaining functional status resulting in less SNF discharges and improving outcomes for older hospitalized individuals (Hastings et al., 2014).  The feasibility of developing such a program aligns with the goals of creating a culture where mobility is the norm and the focus is to help maintain functional status and have patients safely return home.

Implementation Strategy       

Aitken et al. (2011) highlight the Advancing Research and Clinical Practice through Close Collaboration (AARC) model.  The model focuses on using high quality of evidence to inform and support nurses to facilitate EBP changes.  Providing nurses with sufficient information and establishing EPB champions are key ingredients for successful implementation (Aitken et al., 2011).  The AARC model is one effective strategy for disseminating and introducing a mobility program as a new practice change within the organization.  In line with Magnet principles, I would first request to meet with the nurse managers and charge nurses to review retrospective data and discuss current barriers in initiating such a program. 

Next, we would work to identify triggers within the EHR to help identify patients appropriate for a mobility program.  Such trigger criteria can include recent fall information, use of assistive device, or verbalization of fear of falling.  Education tools will be provided to all staff informing them about the findings and benefits of the practice change.

Developing an interdisciplinary team made up of therapist, nurses, physicians, and educators will help to lay the foundation of the purpose of the mobility program and also create a model for sustainability as the program progresses.  In line with the AARC model we would define champions both in nursing and physical therapy to lead the initiatives.  Patient-centered care will also be included in the development of such program. Brochures about mobility will be given to patients and families and bed and chair exercise videos will be made available for patients to watch and participate.  The Institute for Healthcare Improvement (IHI) considers patient-centered care to be one of the six aims for improvement in healthcare (Institute for Healthcare Improvement [IHI], n.d.).  This type of focus will not only empower the healthcare team but also empower the patient to be in control of their care. 

With any implementation, there is risk for opposition to change.  Organization leadership is critical in this type of change, but in the same respect empowering nurses at a grassroots level to own this initiative will lead to its ultimate success.  There is anticipation that the following questions or comments will be made: who is going to do it and everyone is busy.  Clear expectations and functions that make the process part of the daily routine will need to be examined and owned by each of the nurse managers who are implementing mobility initiatives on their units. 

Conclusion

With the execution of any practice change, various steps must be taken to ensure decisions are based on adequate and affirmative results. Evidence-based practice involves many stages including identifying a researchable problem, reviewing and confirming the literature, and implementing change based on evidence.  Developing a PICOT question based on a researchable problem helps the researcher to conduct an in-depth literature review to examine a synthesis of the studies and draw appropriate conclusions to determine if a change in practice is necessary.  In this case, the PICOT question helped to determine the feasibility of implementing a mobility program for patients admitted to the hospital to improve patient outcomes. 

Before developing a PICOT question, formulating research questions to support the problem are identified, and developing a list of keywords help to solidify articles in support of a literature review.  With regards to mobility, the literature review solidifies the PICOT question supporting the need for inpatient ambulation to improve overall patient outcomes.  Implementing change that is supported by the literature needs to be well thought out due to potential concerns and opposition.  Providing educational tools, creating clinical champions, as well and patient engagement  will allow for the most viable outcomes to improve overall patient care when it comes to evidence-based practice.

References

Aitken, L. M., Hackwood, B., Crouch, S., Clayton, S., West, N., Carney, D., & Jack, L. (2011, January). Creating an environment to implement and sustain evidence based practice: A developmental process. Australian Critical Care, 24, 244-254. http://dx.doi.org/10.1016/ j.aucc.2011.01.004

Brown, C. J., Friedkin, R. J., & Inouye, S. K. (2004). Prevalence and outcomes of low mobility in hospitalized older adults. Journal of the American Geriatric Society, 52(8), 1263-1270. http://dx.doi.org/10.1111/j.1532-5415.2004.52354.x

Czapluski, T., Marshburn, D., Hobbs, T., Bankard, S., & Bennett, W. (2014). Creating a culture of mobility: An interdisciplinary approach for hospitalized patients. Hospital Topics, 92(3), 74-79. http://dx.doi.org/10.1080/00185868.2014.937971

David, K. S. (2011, April 4). Formulating the evidence based practice question: A review of the frameworks. Evidence Based Library and Information Practice, 6(2), 75-80. Retrieved from https://ejournals.library.ualberta.ca/index.php/EBLIP/article/viewFile/9741/8144

De Morton, N., Keating, J., & Jeffs, K. (2009). Exercise for acutely hospitalized older medical patients. Cochrane Database of Systematic Reviews, 1, 1-42. http://dx.doi.org/10.1002/ 14651858.CD005955.pub2

Ghimire, E., Colligan, E. M., Howell, B., Perlroth, D., Marrufo, G., Rusev, E., & Packard, M. (2015). Effects of a community-based fall management program on Medicare cost savings. American Journal of Preventive Medicine, 49(6)(), e109-e116. http://dx.doi. org/http://dx.doi.org/10.1016/j.amepre.2015.07.004

Hastings, N., Sloane, R., Morey, M., Pavon, J. M., & Hoenig, H. (2014, November). Assisted early mobility for hospitalized older veterans: Preliminary data from the STRIDE program. The American Geriatrics Society, 62(11), 2180-2184. http://dx.doi.org/ 10.1111/jgs.13095

Houde, S. C. (2009). The systematic review of the literature: A tool for evidence-based policy. Journal of Gerontological Nursing, 35(9), 9-12. Retrieved from Walden Library resources

Institute for Healthcare Improvement. (n.d.). Across the chasm: Six aims for changing the health care system. Retrieved from http://www.ihi.org/resources/pages/improvementstories/ acrossthechasmsixaimsforchangingthehealthcaresystem.aspx

Kovner, A. R., & Knickman, J. R. (2011). Health care delivery in the United States (10th ed.). New York, NY: Springer.

Majid, S., Foo, S., Luyt, B., Zhang, X., Theng, Y., Chang, Y., & Mokhtar, I. A. (2011, July). Adopting evidence-based practice in clinical decision making: nurses’ perceptions, knowledge, and barriers. Journal Of The Medical Library Association, 99(3), 229-236. http://dx.doi.org/10.3163/1536-5050.99.3.010

Padula, C. A., Hughes, C., & Baumhover, L. (2009, October/December). Impact of a nurse-driven mobility protocol on functional decline in hospitalized older adults. Journal of Nursing Care Quality, 24(4), 325–331. http://dx.doi.org/10.1097/NCQ.0b013e3181 a4f79b

Polit, D. F., & Beck, C. T. (2012). Nursing research: Generating and assessing evidence for nursing practice (9th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Stolbrink, M., McGowan, L., Saman, H., Nguyen, T., Knightly, R., Sharpe, J., … Turner, A. (2013, December 27). The early mobility bundle: A simple enhancement of therapy which may reduce incidence of hospital-acquired pneumonia and length of hospital stay. Journal of Hospital Infection, 88, 34-39. http://dx.doi.org/http://dx.doi.org/10.1016/ j.jhin.2014.05.006

Zisberg, A., Shadmi, E., Gur-Yaish, N., Tonkikh, O., & Sinoff, G. (2015). Hospital-associated functional decline: The role of hospitalization processes beyond individual risk factors. Journal of the American Geriatrics Society, 63(1), 55-62. http://dx.doi.org/10.1111/jgs.  13193

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