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Bed rest in a sydney teaching hospital
Arch. Gerontol. Geriatr. suppl. 4 (1994) 3 9 - 4 4 9 1994 Elsevier Science Ireland Ltd. All rights reserved. 0167-4943/94/$07.00
39
BED REST IN A SYDNEY TEACHING HOSPITAL
F. EHRLICH, R.G.
POULOS, C , J .
POULOS, B. B U R R A S T O N , S. LORD
and R. SALGADO School of Community Medicine, U n i v e r s i t y Box 1. K e n s i n g t o n , NSW, 2033, Australia
of New South Wales,
Sydney,
P.O.
SUMMARY This paper looks at two s u r v e y s of bed r e s t , conducted in a general hospital. The f i r s t s u r v e y , conducted early one a f t e r n o o n , assessed the prevalence of bed rest within the h o s p i t a l . It was found t h a t most of the patients (67 ~) were in bed, and nearly half of those (42 ~) were in bed for reasons other than being too sick or unsafe to be up, or because bed r e s t was part of t h e i r treatment. A second s u r v e y , in which a sample of general hospital patients was r e p e a t e d l y observed t h r o u g h o u t the d a y , found that patients with no r e q u i r e ments for bed rest spent 63 % (95 96 confidence limits: 51-75 96) of the active p a r t of the day in bed. It may be t h a t because of the n a t u r e of hospital design, many patients are unnecessarily confined to bed because t h e r e is simply nowhere else to go. I n a p p r o p r i a t e use of bed rest has implications for patient health and the utilization of scarce hospital resources. K e y w o r d s : bed rest in hospital,
hospital design, i n a p p r o p r i a t e bed rest
INTRODUCTION The complications on the cardiovascular
of bed rest are well known and include adverse effects and
respiratory
and bone mass, a r e d u c t i o n tion,
decubitus
deprivation
ulceration,
systems,
in joint mobility, and psychological
( H a r p e r and Lyles,
to these complications ( B o r t z ,
a decrease in muscle s t r e n g t h increased incidence of c o n s t i p a -
problems associated with
sensory
1988). Elderly people are even more susceptible 1982; Hoenig and R u b e n s t e i n , 1991).
However, treatment in an acute hospital setting is c e n t r e d around the bed. Patients role.
are allocated a bed on admission
In many cases not enough attention
patient. result sulting
and
mary
rapidly
assume the
is g i v e n to e a r l y ambulation
This car. r e s u l t in the complications of bed rest,
sick
of the
which may,
in t u r n ,
in delayed r e c o v e r y and thus delayed discharge from hospital.
The re-
d e p e n d e n c y may also place g r e a t e r demands on n u r s i n g
s t a f f and may
r e q u i r e r e h a b i l i t a t i v e e f f o r t s for its r e v e r s a l . It is with this in mind t h a t these two s u r v e y s were u n d e r t a k e n , metropolitan
teaching
hospital.
The main objective
prevalence of bed rest in the patient population, the reasons for i n a p p r o p r i a t e bed rest.
was to collect
in a busy
data on the
as well as to e x p l o r e some of
40 P A T I E N T S AND METHODS Survey I The initial s u r v e y , been given
in 1990, was conducted w i t h o u t any p r i o r notice having
to ward s t a f f .
wards were included,
All medical,
surgical,
rehabilitation
and orthopaedic
w h i l s t the accident and emergency d e p a r t m e n t ,
and intensive care w a r d s , m a t e r n i t y ,
coronary
paediatrics and p s y c h i a t r y were e x c l u d e d .
The s u r v e y was conducted between the times of 1.30 pm and 2.50 pm on a week day.
This
period
avoided
meal or afternoon
tea times.
Information
was
obtained at the bedside from the n u r s i n g u n i t manager or the p a t i e n t ' s personal registered medical
nurse,
staff
by
independent
not w o r k i n g
within
interviewers the h o s p i t a l ) .
basic demographic d e s c r i p t i v e items, bed.
(professional
paramedical
The questions
asked
and
included
and w h e t h e r the patient was in or out of
If in bed, then the n u r s e was requested to indicate which of a number of
possible reasons accounted for t h i s . Survey 2 The second s u r v e y ,
in 1992, followed a sample of hospital
the d a y ,
r e c o r d i n g at t w e n t y minute i n t e r v a l s
in c h a i r ,
moving about, or at t r e a t m e n t ) .
mount of time patients spend in bed,
patients d u r i n g
t h e i r bed status
(e.g.,
in bed,
This s u r v e y aimed to estimate the a-
r a t h e r than merely r e c o r d i n g the p r o p o r -
tions of patients in bed, as done in s u r v e y I . For the purposes of this s u r v e y ,
an observation
of " b e d "
indicated
that
the patient was in bed, or on the bed with the feet elevated. An observation of "chair"
indicated the patient was s i t t i n g
on the edge of the bed,
out of bed in a c h a i r ,
with legs d e p e n d e n t .
or was s i t t i n g
A total of 21 o b s e r v a t i o n s were
made on each patient. The s t u d y took place o v e r six days in M a y / J u n e , All
hospital
chiatric,
patients were e l i g i b l e ,
maternity,
coronary
care,
1992.
with the exception of p a e d i a t r i c ,
intensive
care,
or d a y - o n l y
patients.
psyPa-
tients being d i s c h a r g e d home from the ward on the day of o b s e r v a t i o n or being admitted a f t e r the observation had b e g u n , were also excluded from the s t u d y . Patients for observation
were selected randomly from amongst all of those
eligible on each w a r d . One h u n d r e d and six patients were selected for o b s e r v a tion,
r e p r e s e n t i n g a p p r o x i m a t e l y 52 96 of eligible patients. The observation
These hours about.
covered
period began at 9.00 am and was completed by 4.00 pro. the
period
when most patients
are likely
to be up and
The exact n a t u r e of the s t u d y and the patients being o b s e r v e d ,
was as
far as possible, not d i v u l g e d to ward staff. A t the conclusion of the o b s e r v a t i o n p e r i o d ,
the p a t i e n t ' s
bed rest was obtained from the N u r s i n g Unit Manager.
r e q u i r e m e n t for
41 RESULTS Survey I The i n i t i a l s u r v e y i n c l u d e d 250 p a t i e n t s . o v e r the age of 70 y e a r s
F i f t y p e r c e n t of t h e p a t i e n t s were
(mean age of 67 y e a r s ;
range
16 to 97 y e a r s ) .
The
age d i s t r i b u t i o n of the s u r v e y p o p u l a t i o n is shown in Table I.
Table I AGE D I S T R I B U T I O N
The s u r v e y
OF P A T I E N T S
(SURVEY I ,
n --- 250)
Age ( y e a r s )
Percent and number
<20
2.4 %, n = 6
20-29
2.4 %, n -- 6
30-39
3.6 %, n = 9
40-49
50-59
%, n = 24 8.8 %, n =- 22
60-69
22
9.6
%, n = 55
70-79
25.2 %, n :- 63
80-89
23.6 %, n -- 59
>90
2.4 %, n =- 6
r e v e a l e d t h a t 67 % of all p a t i e n t s were in b e d ,
29 % were out
of bed and 4 % were at t r e a t m e n t or in t h e bathroom. For those p a t i e n t s in bed, 22 96 were c o n s i d e r e d to be too s i c k to be u p , 31% were in bed as p a r t o f t h e i r treatment,
5 % were c o n s i d e r e d
to be too unsafe to be u p .
The r e m a i n i n g 42 %
o f p a t i e n t s in bed were t h e r e b y t h e i r own choice or f o r no medical reason.
Survey 2 In the second s u r v e y ,
68 o u t of 106 p a t i e n t s
were i d e n t i f i e d
by
nursing
u n i t managers as not h a v i n g a n y s p e c i f i c r e q u i r e m e n t s for bed r e s t ( T a b l e I I ) . The
median age of these
68 p a t i e n t s
was 73 y e a r s
(range
20-95
years).
For
these p a t i e n t s a total of 1340 o b s e r v a t i o n s were made ( t h e o b s e r v a t i o n s e x c l u d e d those w h e r e p a t i e n t s had gone available for
observation).
for treatment/investigations
Overall,
63 % (95 % confidence
these o b s e r v a t i o n s found people in b e d , p a t i e n t s in " c h a i r " and " m o v i n g a b o u t " , Further groups
(<65
analysis years,
was
performed
and were t h u s limits:
un-
51-75 %) of
(29 % and 7 % of o b s e r v a t i o n s r e c o r d e d respectively). looking
at
the
65-74 y e a r s ar, d 75 or o l d e r ) .
population The
in
three
sample was not
age large
42 enough to give conclusive statistical
results,
however,
there is some indication
t h a t bed use is g r e a t e r in y o u n g e r people. One h u n d r e d
and n i n e t y - f i v e
observations
on 53 patier.ts with
no special
r e q u i r e m e n t s for bed r e s t , recorded the presence of v i s i t o r s .
S e v e n t y nine p e r -
c e n t (95 % confidence limits:
found
67-91%)
of these observations
patients
in
bed. Finally,
43 patients
s e r v e d having lunch.
with
no special
F o r t y seven p e r c e n t
requirements
for
bed r e s t ,
(95 % confidence limits:
were ob-
32-62 %) of
these patients took lunch in bed. Table II REQUIREMENTS FOR BED REST (SURVEY 2, n = 106)
Percent
and
Bed rest requirements
number
64 %, n = 68
No special requirements for bed rest
15 %, n = 16
Bed rest a specific r e q u i r e m e n t of t r e a t m e n t
6%,n=
%,
15
Patient too sick to be up today.
6 n
=
Unsafe to be up w i t h o u t the assistance of s t a f f
16
DISCUSSION A number of important mention.
Firstly,
neral teaching hospital years, tion.
observations
the age d i s t r i b u t i o n
arising
from tis s t u d y
of the patients
is,
to a considerable d e g r e e , a " g e r i a t r i c "
Recognition of this should act as a powerful of g e r i a t r i c
of
in this ge-
revealed that 50 % of patients were o v e r the age of 70
so that the hospital
velopment
are w o r t h y
to be found
rehabilitation
programmes
institu-
incentive to the planned d e for
early
mobilization
and
to
promote r e t u r n of f u n c t i o n and independence, in addition to the more traditional activities of diagnosis followed by medical or surgical treatment. An acute hospital must be adapted to the needs of the e l d e r l y , t a l ' s most f r e q u e n t customer ( C r e d i t o r , suggests
that older patients
sociated with
their
1993). A s t u d y by Hirsch et al. (1990),
e x p e r i e n c e substantial
hospitalization,
the hospi-
and that e f f o r t s
functional
co-morbidity
as-
must be made to p r e s e r v e
t h e i r functional independence d u r i n g the course of hospitalization. A second cause of major concern is the high p r o p o r t i o n of patients in bed. Of the 67 % of the total who were f o u n d , d u r i n g the f i r s t s u r v e y ,
to be in bed,
almost half (42 %) were in bed by choice b u t for no medical reason.
In the S u r -
v e y 2, those patients with no special requirements for bed rest were spending
43
the majority Activities
of the active p a r t of the day
such as meeting with v i s i t o r s
(between 9 am and 4 pm)
in bed.
and having a meal appear to encourage
patients to be in bed. Whilst
recognizing
traditional
that
the
patient's
freedom
ward design beds are positioned
of choice
along walls with
is
important,
in
chairs placed in-
t e r m i t t e n t l y between beds. With nowhere else to go, patients are not encouraged to get about. comfortable
Simple design changes such as communal ward d i n i n g tables and
television
promote ambulation bed space.
and
sitting
by p r o v i d i n g
In addition,
within the hospital
rooms
where
patients
may
patients with an a l t e r n a t i v e
where possible,
socialise,
to t h e i r allocated
patients could be encouraged
to t h e i r various diagnostic tests.
could
to walk
Getting dressed each day
into s t r e e t clothing would encourage patients to stay out of bed as well as p r o viding
a
therapeutic
activity.
wards would go even f u r t h e r
The
implementation
of
activity
programmes
in
to address the problem of u n n e c e s s a r y and a n t i -
t h e r a p e u t i c bed rest. Previous studies have demonstrated zation can have considerable 1991).
Two systems
cardiovascular strength 1970).
which
and
the musculoskeletal
For an older functional
on nearly
particularly
means a 10 % loss
maintain
effects
that the supine position and immobili-
in
impact
prior
upon
systems.
strength
person who,
independence,
every
with
body system functional
A daily
status
loss of
one week of bed
to hospitalization,
(Corcoran, are the
1,5 ~ of leg rest
(h~.uller,
is j u s t managing
such a decline in muscle s t r e n g t h
to
may mean
the d i f f e r e n c e between independence and dependence. This
study
has shown t h a t
ages t h r o u g h o u t the hospital.
bed rest may be overused by
Attitudes
patients
of all
to bed rest need to change within hos-
pitals such that the "ambient" condition should be for the patients to be out of bed, e x c e p t for p a r t i c u l a r medical reasons ( C r e d i t o r , Whilst nursing
hospitals
staff,
are
having
f e r a b l y d r e s s e d , ambulating, should
reduce
services
because of
shortages
of
s t a f f hours may be being lost in the additonal e f f o r t of n u r s i n g
patients in bed r a t h e r than a bed,
to
1993).
recover
in s e l f - h e l p situations.
Patients who are u p ,
pre-
eating at a table r a t h e r than in or by the side of
more r a p i d l y
by
not s u f f e r i n g
the
deconditioning
and
iatrogenic problems which are associated with bed rest and to which the e l d e r l y are more susceptible.
Thus
in the long term,
nursing
hours
may actually
be
saved, and the period of hospitalization r e d u c e d , b e n e f i t i n g all c o n c e r n e d . REFERENCES B o r t z , W.M. (1982): Disuse and aging. J. Amer. Med. A s s o c . , 248, 1203. C o r c o r a n , P . L . (1991): Use it or lose it - The hazards of bed rest and i n a c t i v i t y . West. J. M e d . , 154, 536-538. C r e d i t o r , M.C. (1993): Hazards of hospitalization of the e l d e r l y . A n n . I n t . M e d . , 118, 219-223.
44
Harper, C.M. and Lyles, Y.M. (1988): Physiology and complications of bed rest. J. Am. Geriatric Soc., 36, 1047-1054. Hirsch, C . H . , Sommers, L., Olsen, A . , Mullen, L. and Wingrad, C.H. (1990): The natural h i s t o r y of functional morbidity in hospitalised older patients. J. Am. Geriatric Soc., 38, 1296-1303. Hoenig, H.M. and Rubenstein, L . Z . I . (1991): Hospital-associated deconditioning an d y s f u n c t i o n . ,I. Am. Geriatric Soc., 39, 220-222. Muller, E.A. (1970): Influence of t r a i n i n g and of i n a c t i v i t y on muscle s t r e n g t h . Arch. Phys. ~I.ed. Rehab. 51, 449-462.
39
BED REST IN A SYDNEY TEACHING HOSPITAL
F. EHRLICH, R.G.
POULOS, C , J .
POULOS, B. B U R R A S T O N , S. LORD
and R. SALGADO School of Community Medicine, U n i v e r s i t y Box 1. K e n s i n g t o n , NSW, 2033, Australia
of New South Wales,
Sydney,
P.O.
SUMMARY This paper looks at two s u r v e y s of bed r e s t , conducted in a general hospital. The f i r s t s u r v e y , conducted early one a f t e r n o o n , assessed the prevalence of bed rest within the h o s p i t a l . It was found t h a t most of the patients (67 ~) were in bed, and nearly half of those (42 ~) were in bed for reasons other than being too sick or unsafe to be up, or because bed r e s t was part of t h e i r treatment. A second s u r v e y , in which a sample of general hospital patients was r e p e a t e d l y observed t h r o u g h o u t the d a y , found that patients with no r e q u i r e ments for bed rest spent 63 % (95 96 confidence limits: 51-75 96) of the active p a r t of the day in bed. It may be t h a t because of the n a t u r e of hospital design, many patients are unnecessarily confined to bed because t h e r e is simply nowhere else to go. I n a p p r o p r i a t e use of bed rest has implications for patient health and the utilization of scarce hospital resources. K e y w o r d s : bed rest in hospital,
hospital design, i n a p p r o p r i a t e bed rest
INTRODUCTION The complications on the cardiovascular
of bed rest are well known and include adverse effects and
respiratory
and bone mass, a r e d u c t i o n tion,
decubitus
deprivation
ulceration,
systems,
in joint mobility, and psychological
( H a r p e r and Lyles,
to these complications ( B o r t z ,
a decrease in muscle s t r e n g t h increased incidence of c o n s t i p a -
problems associated with
sensory
1988). Elderly people are even more susceptible 1982; Hoenig and R u b e n s t e i n , 1991).
However, treatment in an acute hospital setting is c e n t r e d around the bed. Patients role.
are allocated a bed on admission
In many cases not enough attention
patient. result sulting
and
mary
rapidly
assume the
is g i v e n to e a r l y ambulation
This car. r e s u l t in the complications of bed rest,
sick
of the
which may,
in t u r n ,
in delayed r e c o v e r y and thus delayed discharge from hospital.
The re-
d e p e n d e n c y may also place g r e a t e r demands on n u r s i n g
s t a f f and may
r e q u i r e r e h a b i l i t a t i v e e f f o r t s for its r e v e r s a l . It is with this in mind t h a t these two s u r v e y s were u n d e r t a k e n , metropolitan
teaching
hospital.
The main objective
prevalence of bed rest in the patient population, the reasons for i n a p p r o p r i a t e bed rest.
was to collect
in a busy
data on the
as well as to e x p l o r e some of
40 P A T I E N T S AND METHODS Survey I The initial s u r v e y , been given
in 1990, was conducted w i t h o u t any p r i o r notice having
to ward s t a f f .
wards were included,
All medical,
surgical,
rehabilitation
and orthopaedic
w h i l s t the accident and emergency d e p a r t m e n t ,
and intensive care w a r d s , m a t e r n i t y ,
coronary
paediatrics and p s y c h i a t r y were e x c l u d e d .
The s u r v e y was conducted between the times of 1.30 pm and 2.50 pm on a week day.
This
period
avoided
meal or afternoon
tea times.
Information
was
obtained at the bedside from the n u r s i n g u n i t manager or the p a t i e n t ' s personal registered medical
nurse,
staff
by
independent
not w o r k i n g
within
interviewers the h o s p i t a l ) .
basic demographic d e s c r i p t i v e items, bed.
(professional
paramedical
The questions
asked
and
included
and w h e t h e r the patient was in or out of
If in bed, then the n u r s e was requested to indicate which of a number of
possible reasons accounted for t h i s . Survey 2 The second s u r v e y ,
in 1992, followed a sample of hospital
the d a y ,
r e c o r d i n g at t w e n t y minute i n t e r v a l s
in c h a i r ,
moving about, or at t r e a t m e n t ) .
mount of time patients spend in bed,
patients d u r i n g
t h e i r bed status
(e.g.,
in bed,
This s u r v e y aimed to estimate the a-
r a t h e r than merely r e c o r d i n g the p r o p o r -
tions of patients in bed, as done in s u r v e y I . For the purposes of this s u r v e y ,
an observation
of " b e d "
indicated
that
the patient was in bed, or on the bed with the feet elevated. An observation of "chair"
indicated the patient was s i t t i n g
on the edge of the bed,
out of bed in a c h a i r ,
with legs d e p e n d e n t .
or was s i t t i n g
A total of 21 o b s e r v a t i o n s were
made on each patient. The s t u d y took place o v e r six days in M a y / J u n e , All
hospital
chiatric,
patients were e l i g i b l e ,
maternity,
coronary
care,
1992.
with the exception of p a e d i a t r i c ,
intensive
care,
or d a y - o n l y
patients.
psyPa-
tients being d i s c h a r g e d home from the ward on the day of o b s e r v a t i o n or being admitted a f t e r the observation had b e g u n , were also excluded from the s t u d y . Patients for observation
were selected randomly from amongst all of those
eligible on each w a r d . One h u n d r e d and six patients were selected for o b s e r v a tion,
r e p r e s e n t i n g a p p r o x i m a t e l y 52 96 of eligible patients. The observation
These hours about.
covered
period began at 9.00 am and was completed by 4.00 pro. the
period
when most patients
are likely
to be up and
The exact n a t u r e of the s t u d y and the patients being o b s e r v e d ,
was as
far as possible, not d i v u l g e d to ward staff. A t the conclusion of the o b s e r v a t i o n p e r i o d ,
the p a t i e n t ' s
bed rest was obtained from the N u r s i n g Unit Manager.
r e q u i r e m e n t for
41 RESULTS Survey I The i n i t i a l s u r v e y i n c l u d e d 250 p a t i e n t s . o v e r the age of 70 y e a r s
F i f t y p e r c e n t of t h e p a t i e n t s were
(mean age of 67 y e a r s ;
range
16 to 97 y e a r s ) .
The
age d i s t r i b u t i o n of the s u r v e y p o p u l a t i o n is shown in Table I.
Table I AGE D I S T R I B U T I O N
The s u r v e y
OF P A T I E N T S
(SURVEY I ,
n --- 250)
Age ( y e a r s )
Percent and number
<20
2.4 %, n = 6
20-29
2.4 %, n -- 6
30-39
3.6 %, n = 9
40-49
50-59
%, n = 24 8.8 %, n =- 22
60-69
22
9.6
%, n = 55
70-79
25.2 %, n :- 63
80-89
23.6 %, n -- 59
>90
2.4 %, n =- 6
r e v e a l e d t h a t 67 % of all p a t i e n t s were in b e d ,
29 % were out
of bed and 4 % were at t r e a t m e n t or in t h e bathroom. For those p a t i e n t s in bed, 22 96 were c o n s i d e r e d to be too s i c k to be u p , 31% were in bed as p a r t o f t h e i r treatment,
5 % were c o n s i d e r e d
to be too unsafe to be u p .
The r e m a i n i n g 42 %
o f p a t i e n t s in bed were t h e r e b y t h e i r own choice or f o r no medical reason.
Survey 2 In the second s u r v e y ,
68 o u t of 106 p a t i e n t s
were i d e n t i f i e d
by
nursing
u n i t managers as not h a v i n g a n y s p e c i f i c r e q u i r e m e n t s for bed r e s t ( T a b l e I I ) . The
median age of these
68 p a t i e n t s
was 73 y e a r s
(range
20-95
years).
For
these p a t i e n t s a total of 1340 o b s e r v a t i o n s were made ( t h e o b s e r v a t i o n s e x c l u d e d those w h e r e p a t i e n t s had gone available for
observation).
for treatment/investigations
Overall,
63 % (95 % confidence
these o b s e r v a t i o n s found people in b e d , p a t i e n t s in " c h a i r " and " m o v i n g a b o u t " , Further groups
(<65
analysis years,
was
performed
and were t h u s limits:
un-
51-75 %) of
(29 % and 7 % of o b s e r v a t i o n s r e c o r d e d respectively). looking
at
the
65-74 y e a r s ar, d 75 or o l d e r ) .
population The
in
three
sample was not
age large
42 enough to give conclusive statistical
results,
however,
there is some indication
t h a t bed use is g r e a t e r in y o u n g e r people. One h u n d r e d
and n i n e t y - f i v e
observations
on 53 patier.ts with
no special
r e q u i r e m e n t s for bed r e s t , recorded the presence of v i s i t o r s .
S e v e n t y nine p e r -
c e n t (95 % confidence limits:
found
67-91%)
of these observations
patients
in
bed. Finally,
43 patients
s e r v e d having lunch.
with
no special
F o r t y seven p e r c e n t
requirements
for
bed r e s t ,
(95 % confidence limits:
were ob-
32-62 %) of
these patients took lunch in bed. Table II REQUIREMENTS FOR BED REST (SURVEY 2, n = 106)
Percent
and
Bed rest requirements
number
64 %, n = 68
No special requirements for bed rest
15 %, n = 16
Bed rest a specific r e q u i r e m e n t of t r e a t m e n t
6%,n=
%,
15
Patient too sick to be up today.
6 n
=
Unsafe to be up w i t h o u t the assistance of s t a f f
16
DISCUSSION A number of important mention.
Firstly,
neral teaching hospital years, tion.
observations
the age d i s t r i b u t i o n
arising
from tis s t u d y
of the patients
is,
to a considerable d e g r e e , a " g e r i a t r i c "
Recognition of this should act as a powerful of g e r i a t r i c
of
in this ge-
revealed that 50 % of patients were o v e r the age of 70
so that the hospital
velopment
are w o r t h y
to be found
rehabilitation
programmes
institu-
incentive to the planned d e for
early
mobilization
and
to
promote r e t u r n of f u n c t i o n and independence, in addition to the more traditional activities of diagnosis followed by medical or surgical treatment. An acute hospital must be adapted to the needs of the e l d e r l y , t a l ' s most f r e q u e n t customer ( C r e d i t o r , suggests
that older patients
sociated with
their
1993). A s t u d y by Hirsch et al. (1990),
e x p e r i e n c e substantial
hospitalization,
the hospi-
and that e f f o r t s
functional
co-morbidity
as-
must be made to p r e s e r v e
t h e i r functional independence d u r i n g the course of hospitalization. A second cause of major concern is the high p r o p o r t i o n of patients in bed. Of the 67 % of the total who were f o u n d , d u r i n g the f i r s t s u r v e y ,
to be in bed,
almost half (42 %) were in bed by choice b u t for no medical reason.
In the S u r -
v e y 2, those patients with no special requirements for bed rest were spending
43
the majority Activities
of the active p a r t of the day
such as meeting with v i s i t o r s
(between 9 am and 4 pm)
in bed.
and having a meal appear to encourage
patients to be in bed. Whilst
recognizing
traditional
that
the
patient's
freedom
ward design beds are positioned
of choice
along walls with
is
important,
in
chairs placed in-
t e r m i t t e n t l y between beds. With nowhere else to go, patients are not encouraged to get about. comfortable
Simple design changes such as communal ward d i n i n g tables and
television
promote ambulation bed space.
and
sitting
by p r o v i d i n g
In addition,
within the hospital
rooms
where
patients
may
patients with an a l t e r n a t i v e
where possible,
socialise,
to t h e i r allocated
patients could be encouraged
to t h e i r various diagnostic tests.
could
to walk
Getting dressed each day
into s t r e e t clothing would encourage patients to stay out of bed as well as p r o viding
a
therapeutic
activity.
wards would go even f u r t h e r
The
implementation
of
activity
programmes
in
to address the problem of u n n e c e s s a r y and a n t i -
t h e r a p e u t i c bed rest. Previous studies have demonstrated zation can have considerable 1991).
Two systems
cardiovascular strength 1970).
which
and
the musculoskeletal
For an older functional
on nearly
particularly
means a 10 % loss
maintain
effects
that the supine position and immobili-
in
impact
prior
upon
systems.
strength
person who,
independence,
every
with
body system functional
A daily
status
loss of
one week of bed
to hospitalization,
(Corcoran, are the
1,5 ~ of leg rest
(h~.uller,
is j u s t managing
such a decline in muscle s t r e n g t h
to
may mean
the d i f f e r e n c e between independence and dependence. This
study
has shown t h a t
ages t h r o u g h o u t the hospital.
bed rest may be overused by
Attitudes
patients
of all
to bed rest need to change within hos-
pitals such that the "ambient" condition should be for the patients to be out of bed, e x c e p t for p a r t i c u l a r medical reasons ( C r e d i t o r , Whilst nursing
hospitals
staff,
are
having
f e r a b l y d r e s s e d , ambulating, should
reduce
services
because of
shortages
of
s t a f f hours may be being lost in the additonal e f f o r t of n u r s i n g
patients in bed r a t h e r than a bed,
to
1993).
recover
in s e l f - h e l p situations.
Patients who are u p ,
pre-
eating at a table r a t h e r than in or by the side of
more r a p i d l y
by
not s u f f e r i n g
the
deconditioning
and
iatrogenic problems which are associated with bed rest and to which the e l d e r l y are more susceptible.
Thus
in the long term,
nursing
hours
may actually
be
saved, and the period of hospitalization r e d u c e d , b e n e f i t i n g all c o n c e r n e d . REFERENCES B o r t z , W.M. (1982): Disuse and aging. J. Amer. Med. A s s o c . , 248, 1203. C o r c o r a n , P . L . (1991): Use it or lose it - The hazards of bed rest and i n a c t i v i t y . West. J. M e d . , 154, 536-538. C r e d i t o r , M.C. (1993): Hazards of hospitalization of the e l d e r l y . A n n . I n t . M e d . , 118, 219-223.
44
Harper, C.M. and Lyles, Y.M. (1988): Physiology and complications of bed rest. J. Am. Geriatric Soc., 36, 1047-1054. Hirsch, C . H . , Sommers, L., Olsen, A . , Mullen, L. and Wingrad, C.H. (1990): The natural h i s t o r y of functional morbidity in hospitalised older patients. J. Am. Geriatric Soc., 38, 1296-1303. Hoenig, H.M. and Rubenstein, L . Z . I . (1991): Hospital-associated deconditioning an d y s f u n c t i o n . ,I. Am. Geriatric Soc., 39, 220-222. Muller, E.A. (1970): Influence of t r a i n i n g and of i n a c t i v i t y on muscle s t r e n g t h . Arch. Phys. ~I.ed. Rehab. 51, 449-462.