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‘Fit to sit’ in the emergency department

Hospital patients benefit by staying as active as possible – and they can start by waiting in a chair in the emergency department rather than on a trolley.

Hospital patients benefit by staying as active as possible – and they can start by waiting in a chair in the emergency department rather than on a trolley

fit
There are immediate practical benefits for the patient such as
being able to drink more easily. Picture: Alamy

A campaign to get patients out of bed and wearing their day clothes instead of pyjamas, called #EndPJparalysis, has caught the imagination of nurses and other healthcare staff across the country, with many encouraging inpatients to get dressed and moving around as early as possible.

But staff at Nottingham University Hospitals Trust have taken it a step further – starting as soon as patients come into the emergency department with a ‘fit to sit’ campaign. Some patients who arrive by ambulance on a trolley are now being encouraged to sit on a chair and remain as active as possible while they wait to be seen.

Jane Newton, matron in the emergency department, says the system has only just been introduced and is still being worked through. But so far #EDFit2Sit is going down well with both staff and patients.

‘We have a lot of people who come in by ambulance on a trolley,’ she says. ‘And basically they remain on the trolley until they are discharged or go to a ward. But not all of them need to be on a trolley.’

Quicker ambulance handover

She points out that patients who arrive under their own steam or are brought in by relatives or carers often spend their waiting time on a chair.

Patients are assessed for risk of falls or anything that might be affected by sitting rather than lying, and are then moved to a chair if it is deemed suitable and they are willing to sit. The seated waiting area has a member of staff responsible for ensuring patients are okay.

Moving patients off trollies earlier may also mean a shorter waiting time for the ambulance crew to hand patients over so they can move on to the next call.

‘If we can encourage more independence from the start they may be more likely to go home’

Jane Newton, emergency department matron, Nottingham University Hospitals Trust

‘What is important for us is that the work we are doing in inpatient wards around #EndPJparalysis is started in the emergency department. If we can encourage more independence from the start they may be more likely to go home,’ says Ms Newton.

‘Some patients come in and expect to be on a trolley just because they are in hospital. It’s about how you communicate with them and explain it.’

There are immediate practical benefits for the patient such as being able to drink more easily, move around and potentially use the toilet. She says staff want to stress these positives about sitting on a chair, rather than make people feel they have to get off the trolley because they are somehow not seen as being ill enough to be on it.

Psychological impact

Patients who are well enough to sit on a chair may still be admitted as inpatients, but they are likely to be among those will then be encouraged to sit rather than lie in bed, she says.

There is no evidence on the impact of time on a trolley and deconditioning – the loss of strength and independence that occurs when patients lie in bed for days on end. However, there is a good evidence base for the effect on inpatients of spending too much time in bed.

But there may be a psychological effect that starts as soon as patients are taken to hospital – patients who are lying on a trolley may assume they must therefore be very ill and should not move. Encouraging a degree of independence and mobility as soon as possible may help to address this.

‘Staff here have really embraced the idea… with different areas coming up with different ways of putting these principles into practice’

Ann-Marie Riley, deputy chief nurse, Nottingham University Hospitals Trust

Ms Newton plans to assess the effect of the policy, work with the ambulance service and share learning and experience with other hospitals. 

Nottingham University Hospitals deputy chief nurse Ann-Marie Riley says the trust has adopted the pyjama campaign across other areas of its hospitals. ‘Staff here have really embraced the idea and it has grown organically, with different areas coming up with different ways of putting these principles into practice,’ she says.

The campaign was led by Brian Dolan, an NHS-trained nurse who is now working in New Zealand – although some hospitals have had ‘get moving’ schemes for many years.

Effect on muscles

The condition of older people deteriorates if they spend time in bed unnecessarily. A 2008 study found that in healthy older adults 10 days of bed rest results in a substantial loss of lower extremity strength and power, as well as aerobic capacity, and said the effects would be more pronounced for ill older adults in hospital.

This means that a stay in bed in hospital will make it harder for them to get back to their baseline level of functioning – for example, they may need more rehabilitation. Some never get back to it.

So far, the pyjama campaign has been enthusiastically adopted in acute hospitals but it could be used throughout the patient pathway – for example, in community hospitals, in people’s homes and in care homes.  Professor Dolan has stressed it should be about ‘patient choice, dignity and improving safety’ and that people should not be forced to take part.

Introducing ‘fit to sit’ in an ED

  • Many of these patients will come in through the ambulance service – so ensure it is involved in discussions.
  • Patients may need to be screened for selection to eliminate those at risk of falls or other problems, who ought to remain on a trolley.
  • Patients and carers may need an explanation of why a chair is better – concentrate on the positives such as being able to drink easily or go to the toilet.
  • Explain that being on a trolley does not mean they will be treated more quickly.
  • Ensure there is adequate supervision for seated patients and that their condition is monitored.

Alison Moore is a freelance health journalist

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