Delayed Mobilization Impacts Length of Stay and Infectious Complications in Elderly Surgical Patients

Author(s):
Jenelle Pederson; Raj Padwal; Lindsey Warkentin; Jayna Holroyd-Leduc; Adrian Wagg; Rachel Khadaroo

Background:

Surgical admissions are increasing in older and frailer patients, who are vulnerable to post-operative morbidity and mortality. Early post-operative mobilization may reduce adverse events and length of stay (LOS), but little is actually known about the impact of delayed mobility.

Hypothesis:

We hypothesize that delayed mobilization would increase LOS and complications in elderly surgical patients.

Methods:

A prospective cohort study was undertaken.  Overall, 306 consecutive survivors of emergent abdominal surgery aged ≥65 years who required help with <3 activities of daily living were prospectively enrolled at 2 tertiary-care Canadian hospitals. Time until post-operative mobilization (out of bed) was attained from hospital records and a priori defined as ‘delayed’ (>35h) or ‘early’ (≤35h) and analyzed with multivariable negative binomial regression.

Results:

Mean age was 76±7.7 years, 45% were women, and 22% were frail according to the Clinical Frailty Scale. Gallstones (23%), intestinal obstructions (21%), and hernia (17%) were the most performed surgeries. Median time to post-operative mobilization was 19h (interquartile range [IQR] 9-35) and median LOS was 9 days (IQR 6-14). One-quarter (n=74) of patients had delayed mobilization, which was associated with much longer median LOS vs early mobilization (14 days [IQR 10-28] vs 7 days [IQR 5-11] p<0.001). After multivariable adjustment, delayed mobilization was still independently associated with longer LOS (adjusted ratio 1.25, 95%CI 1.05-1.44, p=0.03). These patients had increased all-cause complications (47.3% vs 32.3% p=0.02), major infection (9.5% vs 3.5%, p=0.04), and minor infection (14.9% vs 3.0%, p<0.001).

Conclusions:

Potentially preventable delays in mobilization following surgery frequently occur in elderly patients and are associated with 25% longer LOS and more complex discharge transitions. Elderly patients with longer than expected periods of immobilization are a group to target for evidence-based interdisciplinary discharge and transition programs. However, since delays in post-operative mobilization are also potentially modifiable and may intersect with other less amendable surgical risk factors (e.g., comorbidity or frailty), elder-specific strategies targeting early mobilization need to be evaluated with the aim of preventing adverse surgical recovery.