This study is a comprehensive narrative review, using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement for reporting the results (17).

We searched the following databases on 12.07.2021: Ovid Medline, PubMed, and Scopus. The search strategy included the terms “goal-directed,” “goal-attainment” or “goal-setting,” and “inpatient” or “hospitalization” and “mobility” or “mobilization.” The full search is depicted in the Supplementary Material. Additionally, we screened the bibliographies of included articles, editorials, and guidelines on mobility interventions.

Studies were included if they reported on interventions or investigations targeting goal-directed mobilization in hospitalized internal medicine patients. Although most articles on the topic focus on geriatric patients, we included all articles including adult patients to be more inclusive. Articles were included irrespective of the study design or language.

Articles were excluded if they did not specifically outline mobility or mobilization or if they focused on surgery or specific illnesses, e.g., stroke, multiple sclerosis, spinal cord injury, hip fracture, or coronary heart disease.

Two independent reviewers (JH, FDL) examined the search results regarding inclusion and exclusion criteria based on title and abstract. Disagreements were solved with discussion until consensus was reached. Included papers were read in a systematic approach, focusing on type of study, study goals, the setting, methods, measurements, and the results and conclusion. The study results were qualitatively synthesized and narratively described.

One study involved 200 mechanically ventilated patients (mean age 65 years) on a surgical ICU (16). A daily goal based on the surgical ICU optimal mobilization score (ranging from 0 = no mobilization to 4 = ambulation) was defined by a facilitator and the clinical team and a sign with the target goal was posted at patients' bedside. Early GDM led to higher levels of mobilization measured by this score at ICU discharge, significantly shorter length of ICU stay (7 vs. 10 days), and higher mobility related functional independence at hospital discharge. No effect 3 months after hospital discharge was found regarding muscle weakness and quality of life. However, in both intervention and control group more than half of the participants were lost to follow-up. Further limitations include no blinding for bedside clinicians, lack of generalizability, and different protocols for the control group across study centers (16).

Another early GDM protocol in the ICU involving 50 invasively ventilated patients incorporated active functional activities, such as walking, standing, sitting, and rolling. Patients' goal was to do active exercise with a mobility team (19). The ICU mobility scale was used to calculate the amount of time spent doing active exercise (ranging from 30 to 60 min). Patients in the intervention group experienced higher levels of activity measured by this scale and had a greater duration of active exercise each day (20 min/d in early GDM vs. 7 min/d in the control group). At follow-up 6 months after randomization, there were no differences regarding health-related quality of life, anxiety and depression, ADL, and return to work. However, there was a lower average time of active exercise recorded than prescribed in the study protocol. Furthermore, the sample size was insufficient to detect clinically relevant differences in outcomes. Additionally, participants in the intervention group (mean age: 64 years) were older than the control group (mean age: 53 years) (19).

A post-hoc analysis showed that in both groups of patients with low and high Glasgow Coma Scale, early GDM led to a significant increase in functional independence at hospital discharge (22). Patients with impaired level of consciousness could be safely and effectively mobilized (22).

Another post-hoc analysis focusing on the acuity of patients' illness concluded that speed of mobility recovery was significantly higher in patients with illness of moderate acuity receiving early GDM (23). Furthermore, patients with moderate acuity illness in the control group had the lowest probability of reaching functional independence. As such, there is an unrecognized need for mobilization therapy in this group (23).

Both post-hoc analyses faced similar limitations, as they were designed as post-hoc analyses of a RCT trial (16), where interaction and subgroup analyses were not originally planned (22). Generalisability of the results to all critically ill patients may not be possible (22, 23).

Accelerometers monitored patient's activity in a RCT with 255 patients from a geriatric unit (mean age: 81 years) (20). The intervention group and their therapists were informed about the participants' walking time using daily accelerometer data. Therapists and patients set mobility goals together, including targets for daily walking time. The objectives were re-evaluated weekly and modified according to accelerometer data. In-therapy and non-therapy walking time over 28 days were compared. Non-therapy walking time in the intervention group was higher by about 7 min/day. The median daily walking time, consisting of non-therapy and in-therapy walking time, increased from 10.3 to 32.1 min per day in the intervention group, and from 9.5 to 26.5 min per day in the control group. Median length of stay, readmissions, discharges to a higher level of care, improvements in the short physical performance battery, health related quality of life, and the ADL scale were not significantly different. Although different models of accelerometers were used, the proportions of patients using each device was not significantly different (20).

In a single-blinded RCT, the mobility program consisted of assisted ambulation twice daily and daily mobility goals for additional activity (18). The study included 100 patients with a mean age of 74 years in a veterans study (97% male). Functional outcome was assessed by ADL, measured at admission, retrospectively for 2 weeks prior to admission, at discharge and at 1-month follow-up. Community mobility was assessed by the Life-Space Assessment (LSA), which measures mobility based on the distance reported moving during the last 4 weeks. The score ranges from 0 to 120, with higher scores representing greater mobility. LSA was assessed at baseline and 1-month follow-up. ADL did not significantly change between the groups. However, significant difference in LSA was measured, as the intervention group had a 10-point higher LSA score at 1-month posthospitalization (18).

The STEP-UP program in an inpatient medical-surgical unit investigated 48 patients over a 3-day period (21). The intervention consisted of education, setting daily ambulation goals, and giving ambulation reminders. Patient ambulation was assessed using a pedometer. The amount of ambulation significantly increased on the third day for the intervention group, but not before (21).

Klein et al. designed a quality-improvement project comparing two adult care units (n = 2,164 patients) with each other and to baseline (1,966 patients) (24). Patients had a mean age of 52 years. Patients' goal was a mobility level based on the John Hopkins Highest Level of Mobility (JH-HLM) scale (range: 1 = “lying in bed” to 8 = “walking 250 feet or more”). The goal was posted at patient's bedside, and nursing staff was instructed to implement the intervention. Patients on the project unit met their daily mobility goals more frequently and had higher levels of mobility. JH-HLM scores were significantly higher in the project unit, but no difference in mean JH-HLM goal was found between intervention and control group. The project unit had a higher probability of reaching maximum JH-HLM scores of 3 or greater, and a more than 70% probability of reaching an ambulatory status (JH-HLM ≥ 6) during hospital stay (compared to 60% in the control unit) (24). It was not investigated whether the intervention had effects on length of stay, pressure injuries, number of falls, or number of discharges to rehabilitation facilities. Further limitations include lack of randomization and blinding. Additionally, the project unit included more stroke patients than the control unit (24).

A quality-improvement project on two general medicine units involved 3,352 patients with a mean age of 54 years. Pre-existing staff mobilized patients 3 times/day and daily mobility goals were set. The JH-HLM was used to assess mobility and create daily goals. It was concluded that this intervention was safe and cost-effective, as there was a reduced mean length of stay, but no difference in injurious falls. Patients reaching the highest ambulatory level (JH-HLM ≥ 6) increased from 43 to 70% and improvement in mobility increased from 32 to 45%. Due to the study design, no direct cause-and-effect relationship can be drawn between the intervention and improvement of mobility and reduction of length of stay. Furthermore, there was a higher rate of missing documentation in the first 4 months (26).

Another quality improvement mobility program investigated 954 patients on a surgical and general medical unit at baseline and project period. The mobility program group consisted of 292 patients with a mean age of 64 years on the general medicine ward and 59 years on the general surgical ward. A mobility technician assessed patient's JH-HLM score and mobilized the patient with the goal of increasing the score a minimum of one level per day. Furthermore, the patient was given a goal to improve the score one level daily. Although the JH-HLM score did not change significantly, the goal of improving patients' mobility by one level was achieved. Falls and length of stay decreased in medical patients, and they were more frequently discharged home instead of transferred to rehabilitation facilities. However, none of these outcomes reached statistical significance. Yet, definite conclusions cannot be drawn due to small sample size, short pilot duration, and limited data on demographics of the baseline data group (25).

The WALK-FOR program used a pre-post two-group comparative design to prevent functional decline in older adults (27). It was set in two internal medicine units with 377 patients, 65 years (mean age 75 years) or older. The intervention consisted of addressing the main obstacles to mobility, education, setting the goal of walking 900 steps per day, and removing all mobility obstacles. Nurses assessed participants and steps were counted by an accelerometer. Patients in the intervention group walked significantly more, and the odds of reduction in basic ADL function and community mobility was significantly reduced. There was no significant effect on prevention of decline in instrumental ADL (27).