HIGHLIGHTS
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To identify barriers to in-hospital mobilization, a pilot study of patients undergoing 1-2 level lumbar fusion was performed.
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Of the 30 patients in this pilot study, only 9 ambulated on the first day after surgery.
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The most common reason for not mobilizing was the lack of a floor bed (11), followed by a late surgery start (4) and being on complete bed rest (3).
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Other reasons included incomplete orders (1), no therapist available (1) and presence of neurologic deficit pre-op (1).
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Early patient mobilization is largely dependent on hospital administrative factors rather than patient characteristics or surgical parameters.
Introduction
Early mobilization is a critical component for enhanced recovery for patients after spine surgery .1 Early mobilization reduces the risk of post-operative complications, hastens return to functional walking ability, improves patient-reported outcomes, shortens hospital stays and decreases costs.1 Delayed mobilization leads to ileus, atelectasis, and urinary retention which further prolongs the patients stay in the hospital, which in turn increases patient costs, and overall dissatisfaction.1 Hospitals are also negatively impacted by a patient’s prolonged stay by decreasing the number of available beds and use of additional resources to treat complications. Although there are characteristics specific to patients undergoing spine surgery which can lead to prolonged time before ambulation, there are components that are modifiable that can hasten time to ambulation in the hospital. Thus, there is a need to identify specific barriers to in-hospital mobilization for patients undergoing 1-2 level lumbar surgery.
Methods
After receiving Institutional Review Board approval, the Mini Mental Status Exam (MMSE) was administered to 30 adult patients undergoing a 1-2 level lumbar surgery pre-operatively, in the post-anesthesia care unit (PACU) and one day post-operative (POD1). Standard demographic and surgical data were collected including age, sex, weight, height, ASA grade, BMI (kg/m2), smoking status, comorbidities, current medications, indications for surgery, number of levels performed during surgery, operative time, estimated blood loss (EBL), time spent PACU, daily hemoglobin levels, intraoperative and post-operative transfusion, the total length of hospital stay, and discharge disposition. Whether a patient was mobilized or not within 24 hours after surgery (POD0) was noted. Reasons for not mobilizing within POD0 were also collected.
All statistical analyses were performed using SPSS v28.0 (IBM, Armonk, New York). Data are presented as means and standard deviations continuous variables and frequencies and percentages for categorical variables. Threshold p-value for statistical significance was set a greater than 0.05.Data between patients who were mobilized and those who were not were compared using independent t-tests for continuous normally distributed variables, Mann-Whitney tests for continuous non-normally distributed variables and Fisher’s test for categorical variables. Threshold p-value for statistical significance was set a greater than 0.05.
Results
Nine of the 30 patients were mobilized on POD0 (Table 1). Patients who were mobilized and not mobilized were similar in age, sex distribution, ASA grade, BMI, smoking status, indication for surgery, number of levels fused, operative time, EBL, and time in PACU. Only one patient in the entire study had a blood transfusion and this was intra-operative in a patient who was mobilized. Daily hemoglobin values were similar between the two cohorts. Incidence of ileus, atelectasis and urinary retention were similar between the cohorts. Length of hospital stay in the patients who were mobilized was a day shorter compared to those who were not mobilized but this was not statistically significantly different. MMSE scores pre-op, in the PACU, and at POD1 were similar between the patients who were mobilized and those who were not. Reasons for not mobilizing included no floor bed available (11), late surgery start (4), on complete bed rest (3), presence of neurologic deficit pre-op (1), incomplete orders (1), and no therapist available (1). Discharge disposition was similar in both cohorts with the majority being discharged to home.
Discussion
It has been previously studied that one of the most critical elements to patient enhanced recovery after surgery is early ambulation.2–4 Early ambulation reduces the risk of post-operative complications, thus there is an increased interest in reducing time between surgery and ambulation for spine surgery patients.4 The current study shows that early patient mobilization was largely dependent on hospital administrative factors rather than patient characteristics or surgical parameters. More than half of the patients were not mobilized due to a scarcity of resources including lack of a floor bed, incomplete orders, and no therapist available. The lack of floor beds leads to a cycle of delayed mobilization. Efficient floor bed management may decrease time between surgery and ambulation, decrease post-operative complications, and reduce length of hospital stay.
Offering outpatient surgery for appropriate patients, such as those with a low ASA score and at lower risk for complications may decrease the need for hospital beds and encourage early mobilization. However, this approach also has barriers to implementation, such as the availability of caregivers, social support, and a proper home setting. In addition, some patients may not feel comfortable about going home after spine surgery. Though many of the patients selected for outpatient surgery are shown to be healthier, there is no universally accepted criteria for the selection of outpatient spine surgery.5 The number of outpatient surgeries between 1994 and 2006 has increased 5-fold, with the data showing promising results.5 A recent study of patients undergoing transforaminal lumbar interbody fusions (TLIFs) showed that there was no significant difference between post-operative complication rates between inpatient and outpatient surgeries (9.4% inpatient and 14.0% outpatient).5
To maximize a patient’s eligibility for an outpatient procedure, medical optimization should be the goal before the surgery. It is well known that obesity, high blood sugar, smoking and other modifiable factors can lead to longer surgeries, higher rates of complications, and prolonged stay in the hospital after surgery.6–8 Optimizing these medical factors such as reducing BMI, controlling blood sugar levels, and stopping smoking before surgery may increase the chance for the patient to have early ambulation following in-patient surgery, as well as increase the possibility of having an outpatient surgery. Though patients are often required to stop smoking before a spine surgery, controlling weight and blood sugar is not often enforced to the same extent. By informing patients that they may have enhanced recovery and decreased time between surgery and mobilization, there may be more of an incentive for patients to act on these factors before surgery.
Dural tears may also pose as potential barriers for mobilizing patients after a spine fusion. Depending on the size of the tear, patients may be put on bedrest or admitted to the hospital again post-surgery.9 There is still not a consensus relating to the treatment of anterior and nerve root tears and whether the patients should be admitted to the hospital or placed on bed rest.9 However, there has been an interest in moving away from placing patients on bed rest, even in the presence of a dural tear.10 It has also been shown that early mobilization for patients who have had dural tears repaired are less likely to develop minor complications and are more likely to reduce hospital stay.10
Neurological impairments also serve as a barrier for early ambulation. Severe damage to nerve cells, brain trauma, cerebral palsy, and other neuromuscular disorders may serve as barriers for patients. However, minimal risk exercises and movement while on bed rest may still serve as valuable methods for patient recovery. There have also been studies suggesting that early ambulation will not increase the risk of transient neurological symptoms.11 Therefore ambulation of any degree should serve to benefit the patient.
Conclusion
The current study shows that early patient mobilization was largely dependent on hospital administrative factors, mostly lack of floor beds, rather than patient characteristics or surgical parameters. The lack of floor beds leads to a cycle of delayed mobilization, as delayed mobilization increases the risk of complications, prolonging hospital stay and leading to less availability of floor beds. Potential solutions include identifying patients eligible for outpatient surgery, medical optimization prior to surgery to maximize a patient’s eligibility for outpatient procedures and offering early ambulation in the recovery room even when a floor bed is unavailable.