1. Assisted Early Mobility for Hospitalized Older Veterans
STRIDE
Assisted Early Mobility for Hospitalized Older Veterans
S. Nicole Hastings, MD, MHS
Durham VAMC Geriatrics Research Education and Clinical Center (GRECC), Center for Health Services Research in Primary Care and Ambulatory Care Service
Duke University, Department of Medicine, Division of Geriatrics
Duke Center for the Study of Aging and Human Development

2. Disclosure Statement This work was supported by:
VA Office of Geriatrics and Extended Care (Non-Institutional Care Pilot 558-3)
VA HSR&D (RCD )
The investigators retained full independence in the conduct of this research.

3. Outline Describe STRIDE program Report results of initial evaluation
Program goals
Eligibility criteria
Staff roles
Report results of initial evaluation
Baseline patient characteristics
Outcomes: hospital length of stay, inpatient falls, discharge destination, and ED visits and readmissions within 30 days of discharge

4. Clinical Problem
Hospitalized older adults spend only 3% of their time standing or walking
<5% have physician orders for bed rest
Immobility during hospitalization has many negative physical effects: loss of muscle mass, deconditioning, overall weakness
Poor physical function associated with adverse outcomes
falls, delirium, longer hospital stays, higher rates of discharge to skilled nursing facilities and readmission
Covinsky JAMA (16); Kommuri Arch Med Res (5);
Zisberg JAGS (2); Brown JAGS (9); Murphy Arch Int Med (3)

5. Objectives
To optimize the physical function of older Veterans by increasing the amount of time spent walking during their hospitalization
Key program features
Proactive, no baseline functional deficits required
Early assessment, ideally within 24 hours of admission
Supervised walking, up to 20 minutes daily until discharge

6. Targeted gait and balance assessment
STRIDE Patient Flow
TARGET POPULATION
Patients > 60 admitted to medical service referred by treating physician
NOT ELIGIBLE
Chest pain or angina
Admitted from nursing home
New neurological deficit
Surgery planned
Bedrest order
Unable to follow 1 step command
Non-ambulatory
Targeted gait and balance assessment
Performed by Physical Therapist NO
YES
Safe for STRIDE?
Usual Care
STRIDE Program
1-2 walks daily for duration of hospitalization supervised by Recreation Therapy Assistant

7. STRIDE Staff Roles Physical Therapist Screens consults
Performs baseline balance and gait assessment
Recommends assistive devices and/or gait belt if needed
Identifies activity goals with patients

8. STRIDE Staff Roles Recreation Therapy Assistant
Works with Nursing to plan timing of daily walks
Supervises walks for safety
Reviews activity goals
Provides motivation and encouragement

9. STRIDE Baseline Characteristics
STRIDE participants, n=66
Demographics
Age, mean (SD), y
74. 2 (9)
Sex, % male
98.5
Race, % black
31.8
By yourself, that is without help from another person or special equipment, do you have any difficulty walking for a quarter of a mile, that is about 2 or 3 blocks? At least some difficulty or could not do
Assistive device – canes 58%
Anxious or worried you might fall, past 12 months
Ostir, Arch Int Med 2012 – community dwelling, admitted to ACE unit, no confusion, no “tethers”, the mean (SD) gait speed for patients who completed the gait speed walk was 0.53 (0.25) m/s.
Blankenburg, Clin Respir J Jul 23. – 6 min walk distance in elderly COPD patients 97 meters at admission (little less than double the 58 meters we observed for 2 min test); heart failure patients, the median distance walked on the 6MWT was 213 m (J Card Fail Mar;15(2): Epub 2008 Dec 5).
ME Tinetti
Performance-oriented assessment of mobility problems in elderly patients

10. STRIDE Baseline Characteristics
Functional status of STRIDE participants, n=66
Self-Report
Difficulty walking/ 2-3 blocks,* % yes 65
Assistive device, % yes 48
Falls in past 3 months, % yes 39
Performance Measures
2 minute walk distance (f), mean (SD)
186.5 (92)
Gait speed (m/s), mean (SD)
0.48 (0.2)
Balance score,† mean (SD)
11.8 (3)
By yourself, that is without help from another person or special equipment, do you have any difficulty walking for a quarter of a mile, that is about 2 or 3 blocks? At least some difficulty or could not do
Assistive device – canes 58%
Anxious or worried you might fall, past 12 months
Ostir, Arch Int Med 2012 – community dwelling, admitted to ACE unit, no confusion, no “tethers”, the mean (SD) gait speed for patients who completed the gait speed walk was 0.53 (0.25) m/s.
Blankenburg, Clin Respir J Jul 23. – 6 min walk distance in elderly COPD patients 97 meters at admission (little less than double the 58 meters we observed for 2 min test); heart failure patients, the median distance walked on the 6MWT was 213 m (J Card Fail Mar;15(2): Epub 2008 Dec 5).
ME Tinetti
Performance-oriented assessment of mobility problems in elderly patients
* At least “some” difficulty or can’t do it
† Balance subscale of Performance Oriented Mobility Assessment, max score 16

11. STRIDE Comparison Group
STRIDE, n=66
Wait List, n=28
Age, mean (SD), y
74. 2 (9)
73.3 (10)
Sex, % male
98.5
100
Race, % black
31.8
21.4
Wait List – referred by provider and eligible but program at capacity
P=0.3

12. STRIDE Comparison Group
STRIDE, n=66
Wait List, n=28
Calculated Probability of Readmission Risk Score, %
21.6
19.7
Developed by VA Inpatient Evaluation Center, VHA Office of Quality and Safety
Calculates risk of 30 day readmission based on risk factors including: patient demographics, hospitalization information, previous admissions, medication, lab values and primary or comorbid diagnoses
P=0.3

13. STRIDE Outcomes - Length of Stay
P=0.1
P=0.09
P =0.1 for LOS and for consult to discharge for Wilcoxon
P=0.1 for LOS and 0.2 for consult to discharge for t-test (pooled)
18% of consults received when patient was in “observation” status; majority of these converted to “regular” admission, but obs time not calculated in official LOS measures

14. STRIDE Outcomes STRIDE, n=66 Wait List, n=28 Inpatient Falls 1
Discharge to SNF*
5 (7.6%)
7 (25%)
30-day ED visits
21.2%
21.4%
30-day readmissions
15.1%
14.3%
Discharge to SNF – Fisher’s Exact test P=0.04
* P=0.04

15. Limitations Comparison group Unclear mechanism
Contemporaneous and similar demographically
Small and non-randomized
Unclear mechanism
Impact on physical function?
Or changes in patient confidence and/or provider behavior?

16. STRIDE Summary
STRIDE is safe and well-tolerated by older Veterans hospitalized for medical illness.
Program participants had reduced length of stay, fewer SNF admissions for short-term rehab, and no increase in post-discharge acute utilization.
STRIDE is a promising interdisciplinary approach to promoting mobility and improving outcomes among hospitalized older adults.

17. STRIDE Next Steps Expand program evaluation STRIDE@HOME (PI Peterson)
Program participants to date, n=274
Patient and provider feedback
(PI Peterson)
funded by Office of Geriatrics and Extended Care (558-4)
Future research questions
Optimal “dose” of walking, in terms of total minutes, number of sessions/day, distance.
Understand effects of walking program/ disentangle reasons for reduced LOS: physiologic versus impact on providers

18. STRIDE Physical Therapist
Acknowledgements
Funder: VA Office of Geriatrics and Extended Care
STRIDE Team
Dennis Bongiorni
Helen Hoenig
Bill Jackson
Kendra Monden
Miriam Morey
Megan Pearson
Rick Sloane
Lauri Jugan, MPT
STRIDE Physical Therapist
Ural Kincaid, RTA
Program Assistant

20. STRIDE Daily Walks Day #1 Walks Of those with walk completed:
Minutes walked, mean (SD)
10 (4.5)
Distance walked, (f) mean (SD), median
476.2 (446) , 317
Perceived exertion (0-10), mean (SD)
3.9 (2.4)
Energy level after walk, % improved 71
How you feel overall after walk, % better 90
Falls, %
How did today’s walk affect how you feel? Feel better, worse, same
How important is this walking program to helping you recover

21. Contact Information
S. Nicole Hastings, MD, MHS
Phone: