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Despite the evidence of the adverse consequences of immobility during hospitalization, patients spend most of the time in bed. Although physical activity is a modifiable factor that can prevent in-hospital functional decline, bed rest is deeply rooted in the hospital culture. To attack this, a multidimensional approach is needed. Therefore, Hospital in Motion, a multidimensional implementation project, was designed to improve physical behavior during hospitalization.
The primary objective of this study is to investigate the effectiveness of Hospital in Motion on inpatient physical behavior. Secondary objectives are to investigate the effectiveness on length of hospital stay and immobility-related complications of patients during hospitalization and to monitor the implementation process.
For this study, Hospital in Motion will be implemented within 4 wards (cardiology, cardiothoracic surgery, medical oncology, and hematology) in a Dutch University Medical Center. Per ward, multidisciplinary teams will be composed who follow a step-by-step multidimensional implementation approach including the development and implementation of tailored action plans with multiple interventions to stimulate physical activity in daily care. A prepost observational study design will be used to evaluate the difference in physical behavior before and 1 year after the start of the project, including 40 patients per time point per ward (160 patients in total). The primary outcome measure is the percentage of time spent lying, measured with the behavioral mapping method. In addition, a process evaluation will be performed per ward using caregivers’ and patient surveys and semistructured interviews with patients and caregivers.
This study is ongoing. The first participant was enrolled in October 2017 for the premeasurement. The postmeasurements are planned for the end of 2018. The first results are expected to be submitted for publication in autumn 2019.
This study will provide information about the effectiveness of the Hospital in Motion project on physical behavior and about the procedures of the followed implementation process aimed to incorporate physical activity in usual care. These insights will be useful for others interested in changing physical behavior during hospitalization.
Netherlands Trial Register NTR7109; https://www.trialregister.nl/trial/6914 (Archived by WebCite at http://www.webcitation.org/76dyhdjdd)
DERR1-10.2196/11341
More than 2 million patients are admitted to Dutch hospitals yearly, with a mean admission time of 7 days [
Nevertheless, patients are reflexively put into pajamas, transferred into bed [
The primary objective of this study is to investigate the effectiveness of Hospital in Motion on physical behavior within 4 wards (cardiology, cardiothoracic surgery, medical oncology, and hematology).
Secondary objectives are to investigate the effectiveness on length of hospital stay and immobility-related complications of patients during hospitalization and to monitor the implementation process.
In November 2015, the project Hospital in Motion was started at the University Medical Center Utrecht (UMC Utrecht). Hospital in Motion is a complex multidimensional project primarily designed to improve physical behavior during hospital stay, defined as a decrease in patients’ sedentary behavior (lying) and increase in physical activity (ie, standing, walking, and exercising). This project follows 2 approaches. The first approach focusses on creating a hospital-wide awareness of the high amount of sedentary behavior during the hospital stay and the known associated adverse effects, and the necessity to incorporate physical activity in usual care. The second approach includes the development and implementation of tailored action plans for each clinical ward. In 2016 and 2017, a pilot study was performed on the geriatric department. Preliminary results and gained experiences during this pilot form the basis of this study protocol.
This study will be conducted within 4 wards (cardiology, cardiothoracic surgery, medical oncology, and hematology) of the UMC Utrecht, the Netherlands. Per ward, a tailored action plan will be implemented. The study protocol was assessed and approved by the medical ethics committee of the UMC Utrecht (study protocol number 16-250). Verbally informed consent was obtained from all patients.
An observational study with a prepost design will be used to evaluate the effectiveness of Hospital in Motion on physical behavior. In addition, the implementation process will be evaluated by using a qualitative approach. Data will be collected before and after implementation. The duration of the implementation project is planned for 10 months, starting in January 2018 (
Timeline of the implementation project Hospital in Motion.
Hospital in Motion will be implemented following the step-by-step model of Grol and Wensing (
Education: Education is an important cornerstone for increasing awareness on the importance of physical activity [
Physical activity as part of usual care: For successful implementation, physical activity needs to be incorporated in usual care and all caregivers with direct patient contact need to be involved [
Involving third parties: Involving the social environment (ie, family, friends, or volunteers) to improve inpatient physical behavior, for example, family and visit leaflets with information about the importance of physical activity during hospitalization and tips to improve patients’ physical activity [
Stimulating environment: Currently, hospital wards are not stimulating environments for performing physical activity [
Mobilization milestones: Daily mobilization goals are successful in increasing walking distance, ADL activities, and number of mobilization moments out of bed [
Technology support: Implementing technological applications such as cycle ergometers with interactive screens, activity trackers, or mobile apps to support, stimulate, and measure physical activity [
In total, 160 patients will be included during a period of 2 months (40 patients per ward). Each patient admitted in the specific ward is eligible to participate in this study. Exclusion criteria for participating in this study were delirium and other cognitive impairments, whereby patients who were not able to provide informed consent were excluded. Patients receiving terminal care were also excluded.
Physical behavior will be measured with the behavioral mapping method [
Physical behavior is defined as the percentage of the total observed time that a patient spent in a specific body position. A distinction will be made between lying, sitting (bedside or chair), and moving (standing, transferring, walking, and cycling). The primary outcome in this study is the percentage of time spent lying.
Secondary outcomes are the percentages of time spent sitting and moving, LOS, and the incidence of immobility-related complications (ie, pneumonia, aspiration, chest infection, pulmonary embolism, deep-vein thrombosis, urinary tract infection, and pressure sores) [
Implementation model based on the study by Grol and Wensing.
Demographic characteristics that will be documented are gender, age, admission reason, specialism, the use of mobilization tools (ie, rollator, walker, crutches, or stick), urine catheter (yes/no), infusion (yes/no), and main perceived limitations during physical activity (eg, pain and exhaustion). In addition, the health perception and physical functioning of patients will be assessed.
The subjective believed health questionnaire is used to obtain the health perception, defined as “individual’s experience of physical and mental functioning while living his life the way he wants to, within the actual constraints and limitations of individual existence” [
The Activity Measure for Post-Acute Care (AM-PAC) is a validated measurement instrument based on the activity limitation domain of the International Classification of Functioning, Disability and Health. In this study, the AM-PAC “6-Clicks” measures of basic mobility and daily activity in acute care will be used. These short forms have shown to be valid for assessing patients’ activity limitations in acute care settings [
In this study, per ward 40 patients will be included per time point. This number is based on earlier studies evaluating physical behavior with the behavioral mapping method [
Process evaluations are advised to monitor implementation processes of complex interventions and to evaluate factors of influence on the implementation. In this study, the framework of the medical research council guideline 2008 is followed to guide the process evaluation [
For the caregivers’ survey, questions are formulated focusing on the willingness to change and motivation of the caregivers to help improve patients’ physical behavior. In addition, questions are included to investigate the current state of the 6 topics of the action plan. The scoring of the questions is based on the visual analog scale; a score between 0% and 100% agreement can be given per question. The survey will be sent to all caregivers of the included wards before and after the implementation period.
For the patient survey, the level of encouragement patients perceived from care providers and the environment to be physically active in the past 2 days will be investigated using 6 statements with a 5-point scale. This patient survey will be performed before and after the implementation period. After the implementation, the survey will be supplemented with questions to investigate the success of the implementation of the action plans per ward.
Timeline of process evaluation.
Semistructured interviews with patients and caregivers: After the implementation, semistructured interviews with both patients and caregivers will be undertaken. The interviews will be guided with a topic list based on the 3 key functions of process evaluation as described before [
All statistical analyses will be conducted using IBM SPSS statistics software 25. All outcome variables will be tested on normality with the Kolmogorov-Smirnov test. Patients’ characteristics will be described using descriptive statistics and tested with the Chi-square test, Mann Whitney test, or independent samples t test. Physical behavior is defined as the percentages of the total observed time that a patient spent lying, sitting, and moving. For both the primary outcome (the percentage of time spent lying) and the secondary outcomes (percentage of time sitting and moving), the changes in percentages after implementation will be analyzed. In addition, between-group analyses will be performed per ward. The differences between pre- and postmeasurements will be analyzed with an analysis of covariance, whereby the covariate(s) include baseline variables that may differ between pre- and postmeasurements. If data are not normally distributed, log transformation will be executed before testing.
The process evaluation will be based on the caregivers’ survey, patient survey, and semistructured interviews. Categorical data will be analyzed using Chi-square test and continuous data by using the Mann Whitney test or independent sample t test. To correct for multiple testing, a post hoc multiple comparison test will be performed. The semistructured interviews will be audio recorded and transcribed. Data analysis will follow 3 steps: coding, categorizing, and selecting themes, which will be performed in NVivo 11.
This study is ongoing. The first participant was enrolled in October 2017 for the premeasurement. The postmeasurements are planned for the end of 2018. The first results are expected to be submitted for publication in autumn 2019.
Despite the evidence about the negative consequences of low levels of physical activity, patients still spend most of the day in bed, leading to unnecessary functional decline and new disabilities in ADL [
The Hospital in Motion study has the strength that it contains multiple interventions tailored per ward, developed by a multidisciplinary project team. In addition, it is one of the first known large projects using a multidimensional approach, focusing on the physical environment, caregivers, and patients, instead of only 1 element, to improve physical behavior during hospitalization. Another strength of the Hospital in Motion study is the primary outcome of physical activity. As previous studies mostly included medical outcomes (eg, LOS, remissions, and mortality), levels of physical functioning or frequency of mobilization and the actual amount and change of physical activity have not been evaluated [
Diverse factors could influence the success of the implementation of Hospital in Motion. The action plan is a multidimensional package of interventions aimed to improve physical behavior. It contains multiple interventions aimed to incorporate physical activity in usual care procedures, targeting the whole care system. This strength is a challenge at the same time. Many factors may affect the implementation process, such as the functioning of the project team, caregivers’ motivation and willingness to change, available time, and perceived workload. The appropriate study design has been discussed extensively within the research team because of the possible influence of confounding factors. As this study primarily aims to integrate physical activity in daily hospital care, more classic research designs (ie, randomized controlled trials) are less suitable. By following a step-by-step implementation process and by performing a process evaluation, the authors will provide useful insights into the changes in usual care and the successful and unsuccessful elements of the implementation process.
activities of daily living
Activity Measure for Post-Acute Care
hospitalization-associated disability
length of stay
University Medical Center Utrecht
PB and LMMvD declare to be equally contributing authors, as both of them provided equal contributions in drafting the protocol. PB, LMMvD, KV, and CV designed the framework and methodology. PB and LMMvD developed the research protocol and drafted the manuscript. KV and CV critically revised the manuscript and approved the final version.
None declared.