There is ample evidence that early walking can help surgical patients avoid complications like ileus, deep vein thrombosis (DVT), and pneumonia. So it is not a surprise that York Hospital in York, PA, decided to take a look at walking to reduce some of the postoperative complications that its patients were experiencing. But the team, led by clinical nurse specialist Cindy Stermer, MS, RN-BC, ACNS-BC, took the idea of encouraging walking a step further with its program and added incentives for patients.
“We knew that patients wanted to be home as soon as possible, and a complication like ileus can lead to extra days, even weeks, in hospital stays, adding to costs and reducing patient satisfaction scores,” Stermer explains.
Surgical patients who volunteered to participate in the program were provided with a pedometer and given a set of walking goals dependent on age and health status that could bring them bronze, silver, or gold medals. For example, the gold medal range was from 1,050 steps for someone over 65 with limitations, to 2,250 steps for someone 18-65 years old without any limitations. The silver and bronze medals were awarded to members of the same groupings for 700 to 1,850, and 350 to 1,350 steps, respectively. Participants walked within six hours of admission on the operative day, or by noon on the first postoperative day, depending on the time of arrival and operation.
Stermer explains that the plan was created by physicians, nurses, physical therapists, and other stakeholders to ensure safety, and all the nurses on the pilot unit were required to undergo specific training. The nurses even tested the pedometers’ step count accuracy, and found the pedometers were accurate within a 10% range. Patients who volunteered wore the pedometers around their upper legs and logged their steps with the help of staff as needed. Stermer mentioned that medal-worthy patients took pride in their accomplishments, often goading each other on to do another lap, or informing other patients about the program if they were asked about the medals. There was an air of competition about the place.
The project began in the spring of 2013, and launched again in the winter of 2014 when the Olympics began. The coincidence of the medal ceremonies on television gave the project team a chance to sell more patients on the idea of winning medals for themselves.
All the patients went home with their pedometers — and medals.
But the best part of the program was the outcomes: DVT events declined from 7.69% to zero, and pneumonia rates dropped from 15.38% to 12.5%. Patient satisfaction scores improved in the nursing communications area. There was no change in length of stay, which remained at about four days per patient.
The program is not so prominent these days — not as much documentation, Stermer says. Yet the medal ceremonies continue, as do the pedometer gifts to patients. It remains a single-unit initiative, but a sister unit on the floor where it has run since 2013 is considering incorporating competition into their urge to get patients up and around post-surgery. They have a bariatric patient base and early walking is a good thing for them, too.
“We need to have a revitalization,” she says, noting that the next Olympics are a ways off. Perhaps some other big athletic competition will spur a new push.
She thinks this is a good, easy idea that other hospitals can adopt. Figuring out whether it is working on a data level can be difficult, though, if you are not seriously limiting your patient base to elective surgeries. “It is labor intensive to do a lot of documentation — it can be overwhelming. And if the patient comes in through the ED, then how do you count steps they did?”
She advises: Be sure to capture the time when the patient arrives so you can ensure the initial walk occurs on time. While the patients had space in the electronic record to report steps taken, the reporting process is not necessary to make the program work. They no longer use it. But if you are trying to do a quality project, Stermer says adding a space somewhere in your EHR can be helpful for keeping track of total steps in the day. She also says that while patient understanding of the program always seemed crystal clear, other people on staff did not always know what was going on. Starting over, she would make sure that everyone knew what was going on, including technicians, nursing assistants, and other paraprofessionals who might come into contact with the patient. Anyone can be a cheerleader, and all of those people need to understand the importance of documenting steps in such a program. “If it is not documented, it did not happen, and then you can’t give the patient the recognition they deserve,” she says.
She’s looking for a way to have patients do more of the work, perhaps have them do more of the tracking online, or on paper, and remove the aspect where a staff member has to be around to put the number of steps into a log or EHR.
The addition of incentives really did make a difference, Stermer says. It might be hard to quantify the program, but just from the patients’ chatter, she is sure it got more people involved, at an increasing rate. That is the real win, she says: for such an outcome to continue. Hopefully, the patients bring that sense of accomplishment back home with them and their pedometers.