Staffing-Imposed Immobility in a Multi-site Comprehensive Stroke Center Sample: Are U.S. Stroke Centers Staffing Stroke Units Responsibly?

Abstract

Background: Progressive mobility is an important aspect of hospital stroke unit care for hemodynamically stable patients. We aimed to understand the amount of time stable stroke patients with mobility orders spent out of bed (OOB), along with factors influencing mobility in a United States comprehensive stroke center (CSC) sample.

Methods: Institutional Review Board approval was obtained at participating CSCs for the conduct of an observational study of time OOB in stable acute stroke patients without alerting interdisciplinary staff of study aims. Inclusion criteria consisted of adults with either acute ischemic stroke or intracerebral hemorrhage (ICH) that had written medical orders for mobilization OOB.  Exclusion criteria consisted of patients within 24 hours of stroke onset, diagnosis of transient ischemic attack, non-stroke diagnosis, or active deterioration at the time of planned observation. A threshold for achieving optimal time OOB was set at 3 hours (180 minutes) in a 24 hour period. Data were analyzed descriptively and with nonparametric analyses and multiple linear regression to determine independent predictors of the amount of time OOB.

Results: A total of 4 CSCs participated in the study producing a sample of 336 patient observations: 66% were ischemic stroke, 34% intracerebral hemorrhage patients; average age was 63+14 (median 59; IQR 54, 72) years and 51% were male. Median National Institutes of Health Stroke Scale (NIHSS) score at time of observation was 7 (IQR 3-14). Overall, registered nurse staffing was 1 nurse assigned to a median 4 (IQR 3, 6) patients, and nursing assistant staff were available 86% of the time to help with mobility. Patients were mobilized OOB a median 10 (IQR 0, 30) minutes per 24-hour period, however 46% of patients never were mobilized OOB. Only 8% of patients achieved the minimal 3 hours threshold for OOB time within a 24 hour period, and was associated with nurse assignment of < 4 patients (p = 0.017). Independent predictors of time OOB were the number of patients assigned per nurse (p < 0.001), presence of nursing assistant personnel (p = 0.01), the NIHSS score (p = 0.022) and stroke subtype (p = 0.034).

Conclusions: Stable stroke patients with mobility orders spend a significant amount of time in bed. Inadequate nurse staffing is a significant contributor associated with unnecessary immobility. Hospital administrators should ensure that stroke unit staffing does not exceed 4 patients per nurse, with additional personnel available to assist with mobility to facilitate time OOB.