Why Patients Weaken in Hospital

The hidden consequence of hospital admissions

Something that is being observed more often on geriatric wards is patients coming into hospital to be treated for specific illness, but leaving with less mobility and independence than they were admitted with.

Now known widely as hospital-based deconditioning, this is an area that is getting far closer attention from clinicians as to what is driving it.

As we approach the winter season when hospital admissions are higher, this issue demands an increased focus to combat the hospital pressures associated with this time of year.

Jump straight to…

• • What actually happens to the body when patients stay in bed?
  • Why are hospital patients particularly vulnerable?
  • Why NHS winter pressures could make deconditioning worse
  • What can hospitals do to prevent deconditioning?
  • Why tackling deconditioning needs to be part of NHS winter planning
  • Conclusion
  • FAQs

What actually happens to the body when patients stay in bed?

As well as the psychological effects of staying confined to a hospital bed, such as low mood and motivation, patients can actually experience physical changes from the inactivity alone.

These are some of the proven physical effects that have been observed from prolonged bed rest:

• Muscle loss and reduced strength. Kortebein studied the effects of 10 days strict bed rest on healthy older adults. The findings showed that stair-climbing power and knee extensor strength were significantly lower after the 10 days, as well as a 0.95kg reduction in lean muscle mass over the period.
• Reduced cardiovascular fitness. Kortebein’s same 10-day study recorded a 12% reduction in maximal aerobic capacity, which is the body’s ability to absorb oxygen during physical activity. A reduction in this means that everyday physical tasks take up a greater proportion of energy, making them tired quicker.
• Loss of balance and mobility. In a 2014 study, speeds of various activities were measured before and after bed rest. The findings were that stair ascent time, walking and standing from a chair were significantly lower after the bed rest period.
• Reduced ability to perform everyday activities. The Oxford Age and Aging study showed that 30% of older patients admitted to an acute ward developed new limitations in ADLs (activities of daily living). Strengthening this, functional ability was lower at 4-6 weeks than 2 weeks after admission, showing a measured decline over the study period.

Why are hospital patients particularly vulnerable?

Given that Kortebein’s study was on older patients who were in good health shows just how vulnerable some hospital patients could be to deconditioning.

Older patients are often admitted with existing comorbidities, infections, and suffering from poor nutrition and dehydration. Getting admitted to hospital with these existing health concerns can make the effect of deconditioning more severe for these patients.

Bed rest and reduced movement can not only reduce muscle mass and strength, but leaves patients vulnerable to infections like MRSA and pressure ulcers. Poor nutrition and hydration throughout the hospital treatment increases the likelihood of these things occurring, due to weaker immunity and poorer skin health.

Coupled with the physical condition of the patient, hospital environments can inadvertently encourage patients to stay in bed through not helping them get up and dressed (hence ‘pyjama paralysis’) and not having a comfortable ward chair to transfer into.

Why NHS winter pressures could make deconditioning worse

The winter season brings a maelstrom of pressures to hospitals, many which are outside their control but exacerbate existing issues on the wards. One of the unfortunate side effects of all this is that while fighting these pressures, it makes it harder for staff to prioritise patient mobilisation and rehabilitation.

• Increased admissions. Winter colds, flu and other viruses make older people with weaker immunity more vulnerable, driving admissions for respiratory problems and underlying comorbidities like heart and lung issues. This cohort of patients are more susceptible to hospital-based deconditioning, as covered above.
• High bed occupancy. Frail patients entering hospital with mobility problems are more likely to be inactive, leading to higher bed occupancy.
• Workforce pressures. The workforce is stretched at this time of year from winter flu absences, meaning less resource available to help patients recondition and mobilise.
• Discharge delays. Insufficient capacity in community care homes and lack of available discharge equipment like seating can all add reverse pressure to discharging patients, causing delays.

The consequences of deconditioning are all too common and place additional care burdens on families, community care, and ultimately the hospitals themselves through patient readmission.

The impact of deconditioning for the patient can be quite detrimental as it increases their falls risk, creating potentially more complex post-discharge care arrangements, and crucially reduces their independence and quality of life.

What can hospitals do to prevent deconditioning?

There’s much that hospitals can do to prevent deconditioning, as we have covered extensively in our 10-step guide as part of our clinical guide on hospital deconditioning.

Recording patients’ condition on arrival and using sit-out audits helps bring visibility to what is driving deconditioning on individual wards.

Getting patients dressed in their own clothes and out of bed everyday through the use of appropriate standing equipment and seating goes a long way in helping patients to regain strength and mobility faster.

Another important action is to plan discharge from the date of admission rather than a secondary step, so patients are staff are working towards the same goal from day one.

Why tackling deconditioning needs to be part of NHS winter planning

As well as tackling deconditioning more generally, there is specific benefit in including it as part of NHS winter planning.

It is now named as a well-evidenced harm in the latest NHS discharge guidance. As part of this guidance patients are split into different discharge pathways 0-3, all helping to prioritise the discharge and prevent the delays that are so common at this time of year. Another requirement of the guidance is that discharge lounges must accept non-ambulant patients, so patients can continue rehabilitation but not occupy much needed ward space.

Conclusion

With NHS winter pressures placing additional pressure on hospital services, preventing deconditioning needs to remain an important part of patient care. Encouraging early mobilisation, providing appropriate seating and supporting patients to get dressed and moving all helps reduce the risk of physical decline while in hospital.

Ultimately, preventing hospital-based deconditioning helps patients to maintain their independence, supports timely discharge and reduces additional pressures for families, community care and NHS services.