Abstract

Problem: Recent staffing shortages at post-acute care facilities create discharge delays placing patients at increased risk for developing complications, contribute to added hospital costs, and overwhelm acute care resources. Initial mobilization of surgical patients by the registered nurse at a centrally located, Midwest community hospital is inconsistent although a hospital-wide nurse-driven mobility protocol exists.

Objective(s): The purpose of this Quality Improvement (QI) project was to increase registered nurse documentation compliance of a reformed mobility leveling system and decrease length of stay (LOS).

Methods: Monthly PDSA cycles evaluated the effectiveness of staff education, nurse documentation, and the Johns Hopkins Highest Level of Mobility (JH-HLM) tool to decrease LOS over a 45-day period. Metrics from each cycle were compared to baseline and previous cycle data, then used in subsequent cycles to achieve the desired outcomes. Challenges included the inability to use the EMR for data collection leading to archaic documentation methods. PDSA cycle one nurse documentation was 62% of the unit’s daily census with an average LOS of 4.26 while cycle two nurse documentation was 69% with an average LOS of 3.79 indicating an increase in nurse documentation and decrease in LOS.

Anticipated Contribution to Practice: Revitalizing an existing mobility protocol using evidence-based mobility measures and ongoing monthly staff education improved patient mobility thereby decreasing length of stay while establishing a sustainable culture of mobility. Additional contributions may include decreased patient complications, hospital costs, discharges to post-acute care facilities, and inappropriate therapy consults.

Author Details

Michelle Wright, DNP, ACNP-BC, CCRN, TNS

Sigma Membership

Alpha Lambda

Type

DNP Capstone Project

Format Type

Text-based Document

Study Design/Type

Quality Improvement

Research Approach

Pilot/Exploratory Study

Keywords:

Delayed Hospital Discharges, Post-pandemic Staffing Shortages, Hospital Length of Stay, Nurse-driven Mobility Protocol, Prolonged Bedrest, Patient Complications

Advisor

Teresa Krassa

Second Advisor

Jennifer Durst

Degree

DNP

Degree Grantor

University of Illinois Chicago

Degree Year

2024

Rights Holder

All rights reserved by the author(s) and/or publisher(s) listed in this item record unless relinquished in whole or part by a rights notation or a Creative Commons License present in this item record. All permission requests should be directed accordingly and not to the Sigma Repository. All submitting authors or publishers have affirmed that when using material in their work where they do not own copyright, they have obtained permission of the copyright holder prior to submission and the rights holder has been acknowledged as necessary.

Review Type

None: Degree-based Submission

Acquisition

Self-submission

Date of Issue

2025-11-12

Full Text of Presentation

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Available for download on Friday, November 13, 2026

Click on the above link to access the paper. Embargo period may apply.

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