Introduction

The last few years have brought numerous challenges to health in Portugal, in terms of changing the country's demographic and epidemiological profile, the generalization of population access to quality health care, a strong technological evolution, but also in terms of efficiency and control of public expenditure. This balance, associated with the worsening of the economic and social situation, determines an additional effort to guarantee the efficiency and effectiveness of the health system¹.

The length of stay has an impact on hospital management due to the high costs associated with each episode in the various specialties and also due to the incidence of adverse events, which compromise patient safety, such as the risk of infection, falls or other problems unrelated to the main diagnosis ⁽². The average length of stay in hospitals is often used as an indicator of efficiency, as in identical circumstances, a shorter stay will reduce the cost per discharge, making it possible to ensure continuity of care using less expensive post-hospital settings ⁽³.

Prolonged hospitalization and lack of activity during hospitalization are associated with a functional decline in more vulnerable people⁴. Just five days of bed rest can cause a loss of muscle mass of around 1 kg, contributing to the appearance of the disuse syndrome⁵. Eight or more days of hospitalization are associated with a significant loss of muscle mass and a loss of strength of approximately 7.5 newtons in both sexes⁶. In people with walking ability, the periods of activity in a hospital environment are also very reduced. It is estimated that the median frequency of walking in hospitalized patients is 5.5 minutes per day, being similar between independent and help-dependent people⁷. Elderly people who are able to walk upon admission, when admitted to a medical service, can spend 17 hours a day in bed⁸. In addition to immobility, there is a cumulative effect of hospitalization, illness, comorbidities and frailty.

There is evidence that rehabilitation care is effective in reducing mortality and morbidity, preventing complications, improving functional capacity and quality of life^9-11. However, the economic impact of this care is still not very visible. Thus, the objective of this review is to map the literature on the impact of walking programs on the length of hospital stay. Throughout this study, it is intended to answer the research question “Which gait programs have an impact on the length of hospital stay?”

Methodology

A scoping-type review was prepared considering the guidelines defined by the Joanna Briggs Institute (JBI) for this type of scientific literature review¹². The option for this methodological strategy is based on the need to carry out a preliminary analysis, for a study to be carried out, which will seek to know the economic impact of a gait rehabilitation program developed by nurses in an University Hospital.

The formulation of the research question was based on the acronym PCC (Population, Concept and Context). Thus, as a population, all hospitalized people were considered. The concept includes gait programs, with an impact on the length of stay, with the context being the hospital.

In accordance with the JBI recommendations, the development and implementation of the research strategy took place in three stages, having been carried out in October 2022, in the PubMed, Scielo and PsyInfo databases, limited to articles written in Portuguese and English, published between 2017 and 2022. The Boolean phrase - “(walking or gait or locomotion) and (length of stay) and hospital” was created from the combination of descriptors/medical subject headings (MeSH) and was used in all databases previously described data. An article was also added outside this data search, which is important for the purposes of the study. Walking, according to the International Council of Nursing, is defined as “mobilizing: movement of the body from one place to another, moving the legs step by step; ability to support body weight and walk with an effective gait, with speeds ranging from slow to moderate or fast; going up or down stairs and ramps”¹³. By descriptors in health sciences, gait is the way or style of walking, locomotion is the movement or ability to move from one side to the other, and walking is the intentional locomotion to get somewhere¹⁴. Due to the semantic similarity, throughout the text, all these terms are used as synonyms.

With regard to the type of sources, quantitative, qualitative and mixed studies that respond to the research question were considered. Book chapters and opinion articles were excluded from the review.

The selection of articles was a rigorous and systematic process. Using EndNote software, duplicate studies were eliminated. The Rayyan software enabled a new step of removing repeated data. With this program, two researchers independently and blindly selected articles by title and abstract. Consensus meetings served to reach agreement among researchers on which articles met inclusion criteria. In a second step, the selected articles were fully read and their suitability for the study was confirmed. The reason for exclusion was methodically recorded.

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) model served as the basis for organizing the information and the recommendations presented in the PRISMA-ScR (PRISMA Extension for Scoping Reviews) were also followed for the writing of this paper¹⁵.

The Prisma® diagram (Figure 1) summarizes the entire process of identification, screening, eligibility and inclusion of articles. A data extraction table was prepared, which includes the author of the article, year, location, type of study, objective, participants, intervention, the respective results and conclusions obtained. Subsequently, the data were analyzed and grouped in order to meet the purposes that guided this research. The protocol for this Scoping Review is registered on the Open Science Framework (OSF) platform with the identifier https://doi.org/10.17605/OSF.IO/XWDB6.

Results

The databases search identified 53 scientific papers. After the various selection steps (Figure 1), 24 papers were included in the review. The publications took place between 2017 and 2022, with around 42% of the papers produced in 2020, in the middle of the pandemic. A quarter of the studies come from North America^16-24; although there is scientific production from European^25-29, Asian^30-34, South American^35-38, and Oceania³⁹ countries. Regarding typology, 18 of the 24 studies were randomized clinical trials^{16-21,26-33,36,38-40}, two are literature reviews^23,37, and four are observational studies^22,24,34,35.

Figure 1 PRISMA Diagram 

The scientific papers were analyzed and grouped in different contexts, according to the care needs and pathologies of 9,540 participants that led to hospitalization. Gait programs have been found in people undergoing colorectal^16,18,30, gynecological^19,26, urological²¹, cardiothoracic^31,37,38, hip^32,33,36 and of column²³. In non-surgical patients, programs implemented in acute medical ^17,25,27 and neurology ^22,29 settings, were also identified. Early walking was a strategy used in the different phases of hospitalization, from intensive care^24,28 to rehabilitation units^20,34,35,39.

Despite the variability of the programs, all address gait issues, having been grouped into three categories, multimodal intervention programs^{18,19,22,23,26,30,31,34,35}, such as the ERAS protocol, which are characterized by an integrated approach involving different health professionals in a perspective of perioperative optimization, controlling aspects such as pain, risk of thromboembolism, fasting time, gastrointestinal function and early mobilization; exercise programs^{24,25,28,29,32,36-39} which, in addition to walking, include balance training activities, muscle strength, resistance, among others; and exclusive gait programs, namely assisted gait^16,17,27, suspended gait²⁰ walking by objectives³³ and under financial incentive²¹.

Multidisciplinarity is a characteristic that cuts across most of the studies included in this review, with nurses, doctors and physiotherapists being the most highlighted professionals. Despite the results of this research not reporting directly to the rehabilitation nurse, several studies refer to nurses specialized in gait techniques. Different gait programs, in different contexts and moments of care activity, have shown to have an impact on the length of hospital stay. Clinical and economic indicators were also considered in the analysis of the results.

In most studies, the length of stay is similar between the intervention groups and the control groups^{16-18,21,25,27-29,32,33,38,39}; however, one third of the articles analyzed conclude that gait programs reduce overall hospitalization time by between 1 and 3 days^{19,23,24,26,30,31,36,37}. Only two showed an increase in hospitalization time^20,35, which is associated with people with more serious health conditions. At the same time, three surveys demonstrated a reduction in the length of stay in intensive care^24,37,38. Early walking was shown to be safe, not leading to a higher incidence of clinical complications^{16,18,23,31,33,36,37}, even contributing to its reduction^26,30,37. In turn, the mortality rate^{24,27,28,30,37,39} and hospital readmission^{18,19,23,26,28} were not influenced. After this intervention, patients were more likely to go home after hospital discharge³². Overall, the direct costs associated with hospitalizations, which included walking programs, were lower³⁰.

A lower risk of falls³⁵ and pressure injuries²⁷, hospital indicators of patient safety and quality of care, were results associated with the implementation of gait programs that reflect gains in body balance³², in muscle strength ^22,35,36, mobility^24,25 and functional capacity^{17,23,28,32,35}. A greater number of daily steps¹⁷ and better gait performance were also observed^{20,22,27,32,35}, a predictor of greater mobility in the living space³⁴. At the psychological level, the effects of this intervention are well documented, improving cognition²⁸, reducing anxiety^24,29,32, pain³², depressive states of the person or caregiver^24,28,29, translating into greater satisfaction with health care^19,26,32.

Discussion

Health resources in an acute context are a precious and expensive asset, so reducing the length of hospital stay is an objective in health economics. Rehabilitation care provided in these settings not only reduces hospitalization time, but also reduces avoidable complications, improving health outcomes for the user and family⁴¹.

The ability to walk is an important health indicator, having already been proposed by several authors, since 2009, as the sixth functional vital sign^28,42,43. As it was possible to verify in this review, the literature has shown important correlations between walking ability and health outcomes such as mortality, morbidity, complications and quality of life. Walking is a basic activity, necessary for carrying out the various self-care tasks, as it relates to individual levels of independence^42,44.

The functional decline associated with hospitalization is a reality, and it is possible through mobility strategies to reverse these results^27,28. There are barriers related to the person's health condition, such as pain, medical devices, physical weakness²¹ and health professionals, who often neglect gait assistance due to other concurrent clinical activities¹⁷. A study carried out in a public university hospital in Portugal, with 91 elderly patients admitted to an acute medicine unit, found a functional decline of 63.7% at discharge compared to the previous level of autonomy, measured 2 weeks before hospital admission( ⁴). Another investigation involving 503 hospitalized elderly patients found an incidence of iatrogenic disability of 11.9%. Of the total cases of disability, 81.7% were considered potentially preventable, with mobility incentive programs and shorter bed rest⁴⁵. There is additional evidence that hospitalized people who walk in the corridors daily have a lower risk of dependence in activities of daily living and in instrumental activities during and after hospitalization⁴⁶. The findings bring the possibility of a change from the traditional approach focused on the disease and the affectation, to a new perspective that recognizes the functional status as a clinical vital sign, which can be harmed by hospitalization²⁸.

The gait programs are assumed as a strategy to promote levels of mobility and functional capacity that are easily achievable in a hospital environment, since in some cases they are based on simple interventions, in the domain of self-care and that do not require too expensive resources. Walking is considered one of the most common and accessible ways to exercise⁴⁷. Specialized intervention in gait is reserved for people with clinical complexity and duly identified deficits⁴⁸, in which, although the expenses may be higher in an initial phase of the treatment, the investment is recovered in a few months with the reduction of expenses in health^41,42. In inpatient areas dedicated to rehabilitation, a positive relationship was established between length of stay and functional recovery^20,35. Additionally, early access to rehabilitation care boosted a faster recovery²². Also in Portugal, a mobility program developed by rehabilitation nurses for hospitalized elderly people had a positive impact on balance, gait and functional independence, recognizing the advantage of these professionals' work in an acute context⁴⁹. Rehabilitation nurses can lead walking programs and contribute to the multidisciplinary team's awareness of maintaining inpatients’ walking ability.

This research highlighted the importance given to gait incorporated in multimodal approaches, as it is difficult in these situations to attribute a direct causal relationship between the benefits obtained and the costs associated with it. This is the case of enhanced recovery after surgery (ERAS), which constitutes a paradigm shift for the optimization of perioperative care, which includes mobility and early gait, and which has been proven to reduce recovery time and post-operative complication rates ⁵⁰. The role of ERAS in different surgical contexts was possible to assess in this review, verifying a reduction in the length of hospital stay between one and three days^26,30,31. Other studies corroborate these data - in neurosurgery, the implementation of a protocol promoting early mobility in patients after spinal surgery resulted in a reduction of nine hours of hospitalization time and was a catalyst for the involvement of patients in their postoperative mobility⁹. For hepatectomies, in a survey involving 3,739 participants, length of stay was reduced by 2.22 days in the ERAS group and hospital costs were significantly lower compared to the standard care group (p < 0.0001) ⁵¹. In bariatric surgery, hospital stay, and costs were significantly lower with the ERAS approach, implying an average saving of 21.25% of the total cost of the procedure⁵².

In critical care, a plethora of life-sustaining measures associated with critical and unstable clinical conditions make early mobilization intimidating for professionals. Although safe, programs that promote physical activity, including walking, in mechanically ventilated patients are often avoided. Early mobilization in patients under intensive care measures is associated with a reduction in delirium, lower risk of rehospitalization, of infections and a reduction in the length of stay in the unit, with statistical significance⁵³. Similar findings were found in this review, as they demonstrated a reduction in the length of stay in intensive care units^24,37,38. In a unit for neurocritical, progressive mobility also resulted in a sustained improvement in the level of physical activity of patients and a reduction in the length of hospital stay⁵⁴.

A systematic review identified studies that described the relationship between walking ability and health economic indicators. A better gait performance was associated with a shorter hospital stay, lower risk of hospitalization and significantly lower health costs⁴². In the community, in an elderly population, there was an association of 120 minutes of walking per week with a significant decrease in visits to the emergency department and hospitalization⁵⁵. A study carried out over 4 years, involving 27,431 people without functional limitations and aged between 40 and 79, concluded that the time spent walking was significantly associated with lower health costs⁵⁶. A survey focusing on diabetes concluded that in 10 years, the participants' health expenditure was 5.2% and 8.4% lower, for an increase of 3,000 and 5,000 daily steps, respectively⁴⁷.

In the present review, it was also possible to find, in a hospital environment, the appreciation of walking as a health promotion strategy, guaranteeing the implementation of this activity through financial incentives²¹, professionals allocated only for this purpose^16,17 and health plans of individualized interventions²⁷. Although these programs do not change the length of hospital stay, one study concluded that increasing the walking speed to 0.10 m/s in hospitalized and seriously ill people was associated with better health status, less dependency and fewer days of hospitalization ⁵⁷.

Although it is difficult to account for the gains associated with walking and establish direct and causal relationships with this intervention, the results found in this review indicate that maintaining the ability to walk can be economically beneficial and reduce the length of hospital stay. For the economic analysis, some limitations were found. The inclusion of multimodal programs in the study did not allow explicitly extracting the results in length of stay, related only to walking. Simultaneously, the use of quantitative evaluation measures, such as speed, distance covered and number of steps, which bring objectivity and consistency to the results, are not always present in the studies, making it difficult to aggregate results. It remains to be mentioned that in this review, the direct effects of the gait programs were translated into clinical and non-clinical indicators, such as the length of hospital stay. It is necessary to recognize that the long-term benefits of mobility programs tend to be overlooked in favor of apparent short-term cost savings. Economic evaluations associated with rehabilitation programs are complex to carry out, since the impact of interventions does not always translate into objectively measurable measures of health status⁴¹.

Conclusion

Hospitalization is associated with an increase in health expenses related to the incidence of adverse events, which compromise patient’s safety. At the same time, it is associated with an increase in the functional decline of the most vulnerable people. In turn, the ability to walk is an important health indicator, and is even considered the sixth functional vital sign. Thus, walking programs are assumed as a strategy to promote increased mobility during the hospitalization period. This review made it possible to assess the existence of a multiplicity of programs inserted in different hospitalization contexts, some of them dedicated exclusively to walking and others included in multimodal protocols that translate into immediate results in the improvement of functional decline. This variability of programs does not always allow demonstrating the specific benefit of walking, constituting a limitation of the study. Studies of an economic nature, which support the adoption of these programs are still scarce and economic evaluations in this field do not always reflect the gains obtained by implementing this type of intervention. However, this study suggests that intervention in patient´s gait is associated with the prevention of complications and the improvement of the functional condition, as well as a decrease in hospitalization time and, consequently, a reduction in health costs.