On a Friday morning in mid-October, Jason Kowell of Colorado Springs remembers feeling “a little off.” The 41-year-old father was fixing lunch for his six-year-old son Aaron, bent over to retrieve a container and experienced what felt like “a major sinus headache.” He got Aaron on the bus and off to school, went to his parents’ house for a short visit, then returned home to lie down and take a nap.

When he awoke, Kowell knew things were more than a little off.

“The first thing I noticed was that I couldn’t move my toes on my left foot,” Kowell said. He was initially able to stand and walk to a couch to sit down, but 20 minutes later, he struggled to get up. His speech was “noticeably slurred.” Kowell had a stroke.

The UCHealth Mobile Stroke Treatment Unit rushed Kowell to UCHealth Memorial Hospital Central, where he received treatment for the blood clot that caused his stroke. He survived but was left with very little movement in his left arm and leg.

Kowell’s care over the next month illustrates a pair of seemingly paradoxical goals that leaders and staff at Memorial are working to meet. First, the hospital wants to do everything possible to prevent all patients from falling – including high-risk patients like Kowell. At the same time, they want to ensure that all patients move regularly, based on their condition. For some, that might mean simply rolling over in bed; for others that might mean sitting at the edge of the bed; for others that might mean walking the length of a unit or climbing stairs.

The idea that movement is a must for a post-stroke patient like Jason Kowell or an individual who has suffered traumatic injuries might at first seem counterintuitive – especially when preventing falls is also a priority. But in fact, the opposite is true, said Stacy Appell, clinical director of nursing acute care at Memorial Hospital Central.

The role of mobility in patient health

Appell noted that patients who don’t move for even a few days lose strength quickly. As a result, their risk of falls and medical complications increase, she said.

“People don’t grasp all the bad things that can happen by lying in bed for a week. Every day you are decompensating,” said Appell, who began her nursing career on a cardiac unit, where patients were expected to move, and falls were considered a “never event.”

Appell co-chairs a “core team” at Memorial with Joseph Foecking, director of rehabilitation at UCHealth Memorial Hospitals, that focuses on both mobility and fall prevention through new technology, education and teamwork. Both call mobility a “vital sign” as important as blood pressure or temperature in determining a person’s health.

That’s because studies have long shown that patients who don’t move much are at risk for serious medical problems that threaten patient safety, including pressure ulcers, blood clots, pneumonia and cognitive decline, Foecking said. Those and other issues can prolong patients’ treatment, prevent them from returning home, and even threaten their lives. They also impede a hospital’s ability to provide beds promptly for other patients in need of care, he said.

“If you come in with an infection, let’s make sure we deal with that and not complicate the medical picture by having you be immobile,” Foecking said.

“We are trying to debunk the notion that increasing patients’ mobility will lead to an increase in falls,” Appell said.

Innovative use of AI for fall prevention

Not long ago, Memorial designated a large majority of patients admitted to the hospital as a high fall risk. The result: frequent bed alarms that sent busy nurses and their teams scurrying to investigate.

“We had been very used to putting patients on bed alarms,” said Melanie Engler, clinical nurse manager of an internal medicine unit at Memorial Central. “Putting all patients on alarms became a bit much as far as trying to respond to them all. It was also [overly] restrictive for some patients.”

The approach had an unintended consequence, Engler said: “If everybody is a fall risk, nobody is a fall risk.”

Today, Memorial has implemented a “risk of injury” (ROI) system that uses artificial intelligence (AI) to scour the electronic health record for clues such as confusion, previous falls, impulsivity, and certain medications that point to patients who are at elevated risk of falling and injuring themselves and others. The system also recommends precautions that could prevent a mishap from occurring, Foecking said.

The model’s recommendations are not a substitute for a nurse’s critical thinking, Appell and Foecking both stressed. For example, the ROI system might suggest a lap belt to protect a patient from falling, but a patient who had surgery with an abdominal incision would need a different solution.

The ROI approach enables units like Engler’s “to home in on high-fall risk patients and make sure they have alarms,” Appell said. “We can also make sure we are ready when patients are ready to ambulate.”

Assess and document: Patient movement in preventing falls and enhancing recovery

The move to ROI is inextricably linked to making patient mobility a top priority. Providers are working toward routinely assessing and scoring the level of assistance patients need with a variety of movements, like moving in bed, sitting to stand, walking, or climbing stairs; determining their highest level of mobility; and using that information to develop an individualized plan of care.

The data “helps us set a goal and an expectation for the type of movement you should be doing while you are in the hospital,” Foecking said. With that information, providers can also make informed decisions about what kind of specialized care – physical and occupational therapy, for example – a patient needs to progress and be safely discharged, he added.

Appell emphasized that mobility must be “top of mind” and an integral part of each hospital unit’s workflow. That means assessing patients’ needed level of assistance once a day and determining their capability of movement at least three times a day. That’s still a work in progress on some units, she acknowledged.

“We have to have a thought process of ‘This has to happen,’” Appell said. For the work to have its greatest impact, however, providers – nurses, CNAs, respiratory, physical and occupational therapists and all who contact a patient – must also routinely chart their patients’ movements in the medical record, she added. That’s a vital part of AI’s effectiveness in evaluating risk.

“We have to put in the right assessments if patients are to reach the right [mobility] goals,” she said.

Foecking emphasized that education and training is a major part of the mission to improve mobility and prevent falls. The effort includes providing online learning modules, having nurses shadow and observe physical and occupational therapists, and sending physical therapists to nursing units to demonstrate how to use protective devices, like transfer gait belts, to prevent falls.

“We try to make [the training] a physical activity,” Foecking said. “Let’s teach you how to guard someone. Let’s teach you how to prevent a fall. If someone starts to fall, let’s teach you how to assist that fall so that neither the patient nor you are injured.”

A fall prevention success story and future goals

For her part, Engler said physical and occupational therapists have “played a big role in mobility training for safe movement with bedside staff. They have helped our nurses see the best ways to mobilize each patient.”

In fact, her 32-bed, three-pod internal medicine unit has been a major success story in the drive to reduce patient falls.

She worked with Appell to reorganize nursing assignments. Patients had been assigned based on their acuity. That spread them out across the pods, taxing nurses and other staff to respond when a bed alarm sounded, a particular challenge when the call came from an isolation unit that required donning gowns before entering. The unit switched instead to geographic assignments, with each pod broken down by acuity and staffed by a team of two nurses and a tech. The change dramatically reduced response time, Appell said.

The change also contributed to a 59% decrease in the number of unassisted falls between July 1, 2023, and June 30, 2024, according to Kristy Knox, clinical quality and safety specialist for UCHealth Memorial.  The accomplishment earned the unit a “Humpty Dumpty Award” for the greatest reduction in falls.

Engler also credited the emphasis on safely moving patients for decreasing fall risk, and she encourages her staff to document movement in the medical record with friendly competition. “The more patients are up and moving, the less likely they are to fall with an injury,” she said. “Continuing with [improving] their mobility helps us to prepare them for discharge.”

Slow but steady progression after a stroke

Jason Kowell’s experience at Memorial Central provides another example of the hospital’s commitment to patient mobility.

“Originally, I couldn’t even move,” after the stroke, Kowell said. “If I found myself in the wheelchair, [providers] had to push me.” He slowly progressed, first by standing and then taking small, supported steps on parallel bars. Gradually, with encouragement from his therapists, he took more steps with less support.

Kowell said he expressed his desire to practice walking stairs in anticipation of returning home. His therapists supported him in reaching that goal, and the work began to pay off, he said.

“The first time that I went up the stairs, that’s when I really felt like things were turning around,” he said. “Because I was just slowly trying to go in a straight line, but I was actually getting somewhere.”

As of early November, Kowell said he had pushed his walking distance to 300 feet. He was also regaining some movement in his arm and moving closer to discharge.

“I can move it…. You don’t realize how much movement you’re getting until you look back on what you couldn’t do before,” he said.

Kowell looks forward to continuing to regain strength in his left hand and arm, returning to his job with the Pikes Peak Library, and doing as much with son Aaron as his body will permit, including helping his son to learn to ride a bike.

Physical and emotional support from medical teams

Kowell gave his therapists credit for pushing him forward while also supporting him. “They are really good here about finding out what your current limit is and pushing you to that limit but still being able to back down if there is absolutely something you cannot do, both with the broader things like taking steps or things like hand movement,” he said.

The benefits of movement can be psychological as well as physical, Appell pointed out. She related the story of a nurse caring for a patient confined to an intensive care unit. The nurse entered the patient’s room to help him with some extra exercise, only to find him downhearted. His wife had not been able to visit that day, and he could communicate only through a Spanish-speaking interpreter. The nurse changed the mood with a simple suggestion, said an aide who was present.

“[The nurse] asked him to pick some music on his phone, then they danced while I held the multiple chest tubes he had in place. He smiled the whole time and kept waving down other nurses to come join the ‘dance party,’” the aide said.

“When you treat every patient like a family member, you can’t go wrong,” Appell said.