Assessing and Intervening to Improve Mobility for People with Post-Acute Hematopoietic Cell Transplant: A Quality Improvement Project

Aims: The aims of this quality improvement (QI) project, utilizing a clinically-integrated physical therapist (CI-PT) in an outpatient bone marrow transplant (BMT) clinic, were to describe levels of mobility and performance designed to trigger the implementation of exercise interventions tailored to mobility levels of people post-acute hematopoietic stem transplantation (HCT). Method: The Activity Measure for Post-Acute CareTM outpatient basic mobility short form (AMPAC) was used to stage patients by self-reported mobility level for intervention by a CI-PT. A performance-based Two-minute Walk Test (2MW) was also assessed by the CI-PT. Exercise interventions included patient education and a home exercise prescription appropriate to the patient's mobility stage, with modifications implemented at BMT clinic visits on a weekly to monthly basis. Correlations between Karnofsky Performance Scores (KPS), assigned to patients by BMT physicians and physician assistants, and AMPAC scores were calculated using a “between-subjects” methodology for repeated measurements. Results: 1041 AMPAC scores were collected from 177 unique patients with mean age of 54.9 ± 15.8 years. 62.1% of AMPAC scores were in stages 1, 2 or 3, indicating patients had difficulty with bed mobility (stage 1), mobility in their home (stage 2), or in the community (stage 3). In a subgroup (n = 135) of patients with 2MW assessments the pre-transplant mean walking distance was 162.1 ± 34.5 m, with a decrease to 157.4 ± 34.9 m in the immediate post-transplant period, and a return to pre-transplant level by 150 days post-transplant (173.2 ± 34.4 m). For comparison, the normative 2MW distances for those 55-59 range from 176.4 m to 191.0 m. A moderate correlation exists between AMPAC and KPS scores (r = .59, P < .001). The mobility assessments and tailored exercise intervention was successfully integrated into the BMT clinic workflow using existing space, and was welcomed by patients and clinic personnel. Conclusion: Utilizing A CI-PT in an outpatient BMT clinic team is feasible, with enthusiastic feedback from all stakeholders: patients, providers, and management. Results of this ongoing QI project indicate that a tailored exercise intervention delivered by a CI-PT may help patients address mobility limitations in the post-HCT period. There was a moderate correlation between AMPAC and KPS scores, indicating that the AMPAC may be useful as a self-reported measure of mobility in patients in the post-acute HCT period. CLINICAL RELEVANCE: Exercise moderates the risk of mobility loss in people undergoing HCT, but there are currently no widely adopted guidelines for exercise interventions in standard care for people with HCT. This QI project, with a CI-PT utilizing the AMPAC to tailor the exercise prescription, begins to address the need for pragmatic exercise interventions in this population.