Implementation of Systematic Testing of Basic Physical Function in Hospitalized Adults

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However, systematic assessment of physical function is rarely done, and if so, only in older patients. New strategies for systematic testing of physical function to detect signs of functional decline in all adult patients are therefore warranted. The aim was to implement three basic physical function tests across hospital departments and various diagnoses. Methods Implementation study describing deliverables, activities and survey data among 125 physio- and occupational therapists (PT and OT in 2022 and 2024, monthly audits of patient journals and rehabilitation plans, and number of tests performed, extracted from journal systems. Setting: Major acute university hospital. Three validated tests: the Cumulated Ambulation Score as a measure of basic mobility. The 30-seconds Sit-to-Stand Test and Handgrip strength. Results The number of tests performed improved by 36% from 2022 to 2024. The surveys demonstrated that skills and knowledge were well established. Still, PT and OT reported lack of meaningfulness in their clinical reasoning and failure to see the benefit for the patients regarding the implementation of the 3 tests. While some components were well accepted by staff, others require further development based on key questionnaire findings. Conclusion Overall, the first two years of implementation were successful with a marked increase of 36% in number of tests performed. The PT and OT were well-calibrated and actively engaged in testing, although challenge for the therapists to incorporate test results into clinical reasoning and goal setting together with the other findings. Systematic Testing Physical Function Hospitalized Patients Healthcare Staff Evaluation Implementation Figures Figure 1 Figure 2 Introduction Physical function is a strong predictor of hospital length of stay, complications, readmission, and survival across a wide range of patients, regardless of diagnosis ( 1 – 3 ). Despite this, physical function is rarely assessed systematically using validated tests in daily clinical practice, and if systematically assessed, it is typically limited to older patients. Parallel to the measurement of other organ functions, assessing physical function is a crucial parameter for evaluating and monitoring a patient's overall condition. For example, handgrip strength can be used as a vital sign, comparable to other vital signs such as heart rate, temperature, and respiratory rate ( 4 ). Early detection of declining physical function is essential for the timely implementation of preventive and targeted interventions. Addressing the multiple challenges associated with physical frailty, and/or sarcopenia, is essential, especially as the prevalence of sarcopenia in Europe is expected to rise by more than 70% over the next 30 years ( 5 ). Hospital service use is a major contributor to healthcare costs and expected to rise in Europe as the population ages ( 6 ). Thereby routine systematic testing of basic physical function in hospitalized adult patients is vital for improving patient outcomes, enhancing healthcare quality and improve equality in treatment ( 7 – 10 ). To be used systematically in clinical practice, tests of physical function need to be valid, easily applicable, and not too time consuming. The present implementation initiative chooses the following three tests that all adhere to these qualifications. The Cumulated Ambulation Score (CAS)( 11 , 12 ): Assesses patients' basic mobility defined as the ability to get in and out of bed, stand up and sit down in a chair with armrests, and walk with or without an assistive device with a one-day CAS score from 0–6 points (0 = bedridden and 6 = able to ambulate independent of human assistance indoor). CAS is already widely implemented in hospital departments and municipalities as a simple and effective test for assessing patients in orthopaedic surgery ( 13 ), stroke ( 14 ), geriatrics ( 15 ), internal medicine ( 16 ), and gastrointestinal surgery ( 17 ). The 30-seconds Sit-to-Stand Test (30s-STS): Assesses the number of chair stands the patient can complete in 30 seconds without using the arms and is a proxy measure for lower extremity muscle strength and function ( 18 , 19 ). Handgrip strength (HGS): Widely used as an indicator of overall muscle strength and is included in the European algorithm for sarcopenia assessment, with cut-off values set at 27 kg for men and 16 kg for women ( 18 ). HGS serves as a fundamental metric in assessing muscle function and overall physical capability and is particularly relevant to the ageing population. HGS is closely linked to sarcopenia, a condition characterized by the age-related decline in muscle mass, strength, and function ( 18 , 20 ). HGS has also proven to be a strong marker of functional decline and mortality, as a decrease in HGS over time is associated with disease profiles ( 4 , 21 – 25 ). This approach uses handgrip strength as an indicator of general muscle strength and is recognized internationally as a key measure in evaluating physical function, especially among older patients. The systematic assessment aims to support early identification of reduced physical function, enabling timely and targeted interventions during hospital stay( 20 ) The primary aim is to describe the implementation process, questionnaire surveys and audits conducted to assess the implementation of the 3 tests. Methods Design Implementation study. Equator network, STaRI and The Quality Implementation Framework (QIF) ( 26 , 27 ) has been used to structure the reporting in this paper. Implementation At the Department of Physical- and Occupational Therapy, Copenhagen University Hospital, Bispebjerg and Frederiksberg we implemented systematic testing of basic physical function across multiple departments and diagnosis. The hospital is one of the major acute university hospitals in the Copenhagen area with approximately 465 beds. The initiative involved Departments of Orthopedic Surgery, Neurology, Geriatrics, Respiratory disease, Abdominal surgery and Medicine, Cardiology and Emergency. This involved collaboration among hospital leadership, research- and implementation therapists, physiotherapist and occupational therapists (PTs and Ots), staff leaders, the patient journal system, and researchers. Dedicated project PTs and OTs ensured consistent calibration, supported by instructional videos, a dedicated homepage, and departmental presentations ( 9 ). To assess information from at staff, view questionnaire surveys were conducted in 2022 and 2024, assessing the PTs and OTs response to the systematic testing and to identify areas with a need for further focus in the ongoing process. In this first period of implementation, the systematic testing of physical function was implemented for patients referred to Physical- and/or Occupational Therapy for evaluation of their functional level from Orthopedic Surgery, Neurology, Geriatrics, Respiratory disease, Abdominal surgery and Medicine, Cardiology and Emergency. The implementation began by engaging key stakeholders and securing leadership support to establish structure, funding, and resources. A core implementation team, including clinical champions, was formed to ensure high staff involvement from the outset. Three simple, evidence-based physical function tests (bed mobility, transfer ability, ambulation) were selected for their relevance to both acute care and post-discharge planning ( 9 , 25 ). Staff received targeted training, and regular feedback loops were used to monitor fidelity, address barriers across departments, and refine workflows. The integration of the three tests, illustrated in Table 1 , provides simple yet evidence-based assessment of physical function levels in hospitalized patients. Table 1 , physical function. The initial evaluation and first mobilization attempt are conducted as early as possible after referral. Upon discharge or at the end of therapy, a final assessment is conducted to evaluate progress. Additionally, results of the three tests are reported in the rehabilitation plan forwarded to the municipal. Timeline for in-hospital use of the three tests of physical function Test / timepoints Before admission Initial evaluation / first mobilisation attempt Initial evaluation (if possible, otherwise the following days) Upon discharge / end of therapy Plan for rehabilitation forwarded to the municipality Cumulated Ambulation Score, 0–6 point X X X X Handgrip strength, dominant hand, kg X X 30s – Sit-To-Stand test, number of stand ups X X X Questionnaire survey Data were collected through eight target questions in 2022 and 2024 to assess progress and identify areas needing further attention. The implementation team group develop questions and used some background literature when designing the questions and considering what would be important to ask about ( 20 , 28 , 29 ). Knowledge, Skills, Integration, Reasoning, Benefit, Prioritization, Automation, with answers given on a five-point Likert scale (Strongly agree, agree, neither agree nor disagree, disagree, strongly disagree) and for Self-efficacy on a numeric rating scale (0–10, with 0 indicating no self-efficacy and 10 high self-efficacy) (Fig. 2 ). The questions focused on various aspects of the implementation Knowledge: I have knowledge of how to perform the tests and record them in the electronic patient journal. Skills: I have the practical skills to perform the tests and record the results in the electronic patient journal. Integration: I see performing the tests as a natural part of my work. Reasoning: Performing the tests and using the results contribute to my clinical reasoning. Benefit: Using the test results benefits the patients. Prioritization: I prioritize performing the functional tests even when I have other urgent. Automation: Performing the tests and using the results is something I do automatically. Self-efficacy: How confident are you that you will be able to functionally test all your patients next week, even if, for example, you are very busy, there is illness in the team, the patients are tired, etc.? (Fig. 2 ). Audits Monthly data completeness audits were implemented from late 2022 through collaboration between the research department and therapist leaders across all departments. In early 2024, an additional audit evaluated whether physical function test results were properly documented in rehabilitation plans sent to municipal services at discharge. These audits assessed implementation effectiveness, including departmental test workflows, strategies to increase testing rates, documentation in patient records, and successful transfer of information to municipal rehabilitation plans. The number of tests performed was retrieved from the journal system by extracting data on all tests conducted across wards for 6 months from July to December in both 2022 and 2024. This approach provided an overview of the implementation strategy and its progression over time, allowing for an assessment of trends in test utilization and the direction of implementation efforts (se Fig. 1 ). Results Overall, the implementation of the three tests improved from 2022 to 2024 with a marked increase in number of patients being tested with all three tests, see Fig. 1 for details. Notably, HGS testing increased by 49%. Results and key deliverables The implementation strategy was built on evidence from prior research and Danish cohort data, ensuring strong reference materials that aligned with hospital needs, available resources, and existing policies. Danish cohort studies provided evidence-based, age-decade and sex-specific reference values for the selected physical function tests, establishing a solid foundation for clinical decision-making. Full institutional support was secured from hospital leadership, ensuring alignment with organizational priorities and strategic goals. Hospital leadership and key organizational leaders were engaged from the project's inception to build institutional support and gather valuable feedback on implementation planning. Five multidisciplinary teams were established to oversee all aspects of planning, monitoring, and adaptation throughout the implementation process, ensuring comprehensive coverage across departments. Evidence-based algorithms and reference values were integrated, supported by instructional videos and standard operating procedures (SOPs) to ensure consistent testing protocols (see Table 1 for patient testing timeline). Financial and material resources were secured to support sustainability and ensure long-term integration of testing protocols into routine clinical workflows. Staff received thorough training through multiple modalities, including instructional videos (available at www.BBH.fysisk-funktion.dk ), written SOPs, and department-wide presentations to ensure testing fidelity across all clinical areas. Implementation staff conducted presentations and facilitated discussions during departmental staff meetings. Additionally, experienced scientists participated in selected patient testing sessions to identify barriers and discuss solutions for integrating assessments into daily practice. Regular coaching, technical assistance, and workshops were provided to maintain implementation quality and address emerging challenges. Systematic progress tracking and feedback collection enabled adaptations and continuous improvement throughout the implementation process. Implementation challenges were systematically identified and addressed through twice-monthly local group meetings (medical ward, stroke unit, musculoskeletal ward) and monthly leadership meetings for ongoing evaluation. Common barriers including variations in staff engagement and perceived meaningfulness of the tests were actively addressed through targeted interventions and ongoing dialogue with clinical teams. Results of survey, audit and performance monitoring. PTs and OTs demonstrated a well-established knowledge base and possessed the necessary skills to effectively conduct the three tests in both 2022 and 2024. Notably, there was a slight improvement in their skills in 2024 compared to 2022. This progression suggests ongoing development and refinement of their expertise over time (Fig. 2 ). The integration and reasoning aligned with the strategy were observed in only about 50% of the PTs and OTs responses. This pattern was consistent across both the 2022 and 2024 data, indicating that while some PTs and OTs incorporate strategic reasoning in their use of the three tests, a significant portion does not fully integrate it (Fig. 2 ), illustrating integration and reasoning. Approximately 50% of PTs and OTs do not fully recognize how the strategy can benefit one-on-one patient treatment, and this trend remains consistent in 2024 (Fig. 2 ). In terms of prioritization, the responses were notably divided. Around half of the PTs and OTs express, either agreement or strong agreement with the prioritization approach, while the other half showed a contrasting viewpoint, disagreement or strong disagreement. This division highlights a significant variation in how PTs and OTs perceive and approach prioritization, suggesting that there are diverse perspectives and possibly differing interpretations or experiences with the strategy in practice (Fig. 2 ). About half of the responders do not view the three tests as something they do automatically. However, there is a slight improvement in 2024, with more respondents agreeing or strongly agreeing that using the test and the results are something they do automatically. This indicates a shift toward the perception of the tests being integrated into everyday practice (Fig. 2 ). The last question, which concerns PTs and OTs self-efficacy in testing patients next week despite potential scheduling challenges and a busy calendar, revealed that approximately half of the PTs and OTs were confident they could conduct the tests. This self-efficacy shows a slight improvement in 2024, with a greater number of PTs and OTs expressing certainty that they will be able to perform the tests. This trend suggests that, over time, PTs and OTs have become more confident in managing their schedules and prioritizing the necessary tests, even in the face of competing demands (Fig. 2 ). The implementation of systematic testing for basic physical function in hospitalized adults was found to be good regarding PTs and OTs describing good overall knowledge and skills necessary for the systematic testing in the clinic. However, nearly 50% of PTs and OTs reported difficulties in recognizing the direct benefit of the tests during one-to-one patient interactions. Throughout the implementation period, no adverse events were reported in relation to either the implementation strategy activities (training, coaching, audits) or the administration of the three physical function tests (CAS, 30s-STS, handgrip strength). The implementation process and testing procedures were well-tolerated by both healthcare staff and patients. Discussion The systematic implementation of physical function testing across hospital wards and diagnoses has been successful, demonstrating significant progress in increasing the number of patients tested - a primary goal of the initial implementation phase. The data from surveys conducted in 2022 and 2024 indicates a positive trend in PTs and OTs competence and self-efficacy regarding the three tests (Fig. 2 ). Also, data from 2022 to 2024 showed an increasing number of patients being evaluated using the three tests. However, several areas seem to require further and ongoing attention and close connections to leadership and implementation team to ensure the sustainability and integration of these practices into everyday hospital routines. Enhancing staff coherence and addressing concerns about the perceived meaningfulness of the testing emerged as key areas for improvement. These findings suggest that additional efforts may be needed to integrate the testing more effectively into clinical practice and to highlight its value in patient care and sector transitions. What worked well! A very important goal in the first years of implementation was to reach complete data and that more and more patients were tested, this worked well across departments and was very successful overall. The development and application of the implementation strategy were largely successful. The comprehensive approach, built upon prior evidence and Danish cohort data, ensured that the selected tests were well-suited to the hospital context and the needs of the patients. The engagement of key stakeholders, particularly hospital leadership, was critical to aligning the initiative with institutional priorities and securing the necessary resources for long-term success. The formation of multidisciplinary implementation teams, supported by training courses, instructional videos, and standard operating procedures (SOPs), ensured a consistent application of the tests across different wards. Training and continuous support, such as coaching and workshops, were instrumental in maintaining the quality of the implementation. PTs and OTs demonstrated well-established knowledge and skills in 2022, with slight improvements noted in 2024. This ongoing development highlights the success of the structured training and support provided to staff. The engagement with stakeholders and the availability of clear instructional materials contributed to high levels of participation and enthusiasm for the implementation. The increase in tests performed between 2022 and 2024 indicates a notable improvement in the implementation strategy, reflecting enhanced engagement and adherence. HGS testing demonstrated a substantial rise, suggesting a greater focus on assessing muscle function and ease of test. This increase may be attributed to improved awareness, streamlined procedures, or greater accessibility of testing and available HGS devices. These results highlight the effectiveness of the implementation strategy and underscore the potential for further optimizing screening efforts in clinical settings. Areas for improvement Despite these successes, some challenges remain. One notable finding was that approximately 50% of PTs and OTs did not see the direct benefit of the tests in one-on-one patient treatment. This suggests that while the tests are being administered, the broader value of integrating test results into routine care is not yet fully perceived by a significant portion of the clinical staff. This issue remained consistent across both in the 2022 and 2024 surveys, signaling the need for further efforts to communicate the strategic importance of the tests and their direct impact on patient care. A possible approach to addressing the issue would be to establish specialty-specific clinical reference values - such as psychometric indicators like MDC, MCID, and related metrics - that therapists can integrate into the goal-setting process and clinical reasoning to enhance the precision and measurability of therapeutic goals and rehabilitation efforts. Similarly, responses regarding the prioritization of the tests were divided, with PTs and OTs offering a wide range of perspectives. Half of the PTs and OTs agreed with the prioritization approach, while the other half disagreed. This division points to the varied perceptions of how the tests should fit into the broader clinical workflow. Future efforts should focus on clarifying the role of these tests in patient care and aligning the team on their importance to ensure more uniform support and prioritization. Another area for improvement relates to the automation of using the tests. While there was some progress between 2022 and 2024, with more PTs and OTs acknowledging that they automatically conduct the tests, approximately half of the respondents still do not view the tests as part of their daily routine. This suggests that while the tests are becoming more integrated into clinical practice, full automation and routine application have not yet been achieved. Continued efforts to embed these tests into the daily workflow and ensure that they are seen as an integral part of patient care are necessary. Positively, the PTs and OTs self-efficacy in performing the tests despite busy schedules and potential scheduling challenges improved slightly between 2022 and 2024. This trend suggests that PTs and OTs are becoming more confident in managing their time and prioritizing these tests. However, the need for sustained improvement in this area remains, as a portion of PTs and OTs still express uncertainty about their ability to conduct the tests in the face of competing clinical responsibilities. In a similar implementation study by Ibrahim et al ( 20 ) it was shown that implementing routine grip strength measurement by training a large cohort of nurses was feasible, acceptable, and cost-effective in hospital settings. The key factors supporting successful uptake included strong motivation from ward champions, clear managerial backing, and a shared commitment among staff. The process enabled the identification of a high proportion of older patients at risk of adverse health outcomes and created opportunities to fast-track patients with normal strength from admission to discharge, potentially reducing hospital length of stay. Using three validated tests in this present implementation will increase identification of patients at risk of adverse advents. The strategy moving forward. The implementation of physical function testing in hospital settings requires a comprehensive and adaptive strategy ( 30 , 31 ). The mixed responses on prioritization, perceived benefit, and automation highlight that further efforts are needed to enhance staff engagement and increase the meaningfulness of the tests in the eyes of PTs and OTs .The structured training and the provision of resources such as instructional videos and SOPs have been effective, but additional strategies are needed to reinforce the relevance of the tests and ensure their full integration into clinical practice. Moving forward, the continued application of frameworks such as the Quality Implementation Framework (QIF), the PDSA (Plan-Do-Study-Act) cycle and Knowledge-To-Action (KTA) model ( 26 , 32 ) will be essential to refine the implementation strategy ( 26 , 33 ). These frameworks will allow for ongoing assessment and adaptation, ensuring that challenges are identified and addressed in real time. Continuous feedback from PTs and OTs will be vital in understanding the barriers to full adoption and ensuring that the tests are not only conducted but are seen as an integral part of patient care. Conclusion The introduction of systematic physical function testing in hospital wards from 2022 to 2024 improved PT and OT knowledge, skills, and perceived? self-efficacy. The structured, evidence-based approach increased testing rates - especially for handgrip strength - and made these assessments more routine. However, only about half of clinicians see clear patient benefits, and some still question the tests’ priority and automation. While technical competence and self-efficacy under time pressure have grown, full integration into daily practice remains incomplete. Perspectives Insights from the 2022 and 2024 surveys are vital for refining strategies, as they highlight staff experiences and operational barriers with physical function testing. Integrating survey feedback will help address persistent issues. Tailored interventions and training can then target these gaps. Empowering local champions within clinical teams is also key to driving engagement and cultural change. Datasets generated in the present study are not publicly accessible due to Danish data sharing agreements but may be obtained from the corresponding author upon reasonable request. The study was conducted in accordance with the Declaration of Helsinki and approved by the local Danish ethical committee (2301–6039). Declarations Ethics, Consent to Participate, and Consent to Publish declarations: not applicable. Clinical trial number: not applicable Funding: Danish Physiotherapy Association and the Department of Physio- and Occupational Therapy Bispebjerg Hospital, Copenhagen, Denmark. Author statements. We have no Conflict of Interest Author Contribution Author contributions: CHD, MAA, CS, and MTK conceived and designed the work; CHD, CKM, CHA, TB, NMH, MAA, CS, and MTD contributed to data acquisition, analysis, and interpretation; all authors have substantially revised the manuscript. Data Availability Datasets generated in the present study are not publicly accessible due to Danish data sharing agreements but may be obtained from the corresponding author upon reasonable request. References Scheerman K, Meskers CGM, Verlaan S, Maier AB, Sarcopenia. Low Handgrip Strength, and Low Absolute Muscle Mass Predict Long-Term Mortality in Older Hospitalized Patients: An Observational Inception Cohort Study. J Am Med Dir Assoc. 2021;22(4):816–e202. 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Dall","email":"data:image/png;base64,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","orcid":"","institution":"Bispebjerg Hospital","correspondingAuthor":true,"prefix":"","firstName":"Christian","middleName":"Have","lastName":"Dall","suffix":""},{"id":546965538,"identity":"3e63073e-20c8-4772-8971-5bad4477abc3","order_by":1,"name":"Camilla Kampp Zilmer","email":"","orcid":"","institution":"Bispebjerg Hospital","correspondingAuthor":false,"prefix":"","firstName":"Camilla","middleName":"Kampp","lastName":"Zilmer","suffix":""},{"id":546965534,"identity":"77749e66-3cee-4ec8-84be-827c99b9c392","order_by":2,"name":"Durita Viderø Gunnarsson","email":"","orcid":"","institution":"Bispebjerg Hospital","correspondingAuthor":false,"prefix":"","firstName":"Durita","middleName":"Viderø","lastName":"Gunnarsson","suffix":""},{"id":546965530,"identity":"f5ab89f2-5689-4ba0-90ef-1f6319ba2a68","order_by":3,"name":"Christian Hedelund Arens","email":"","orcid":"","institution":"Bispebjerg Hospital","correspondingAuthor":false,"prefix":"","firstName":"Christian","middleName":"Hedelund","lastName":"Arens","suffix":""},{"id":546965531,"identity":"f4f4ead1-c2a9-425d-b733-b667ac1ac49b","order_by":4,"name":"Theresa Bieler","email":"","orcid":"","institution":"Bispebjerg 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12:13:35","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":99088,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8079989/v1/2ca60b34ee3711e9153f4d5d.html"},{"id":96364867,"identity":"054ffb62-eaac-4196-9821-3dde7785a8a6","added_by":"auto","created_at":"2025-11-20 10:09:44","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":20729,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eNumber of Tests Performed (July to December) in 2022 and 2024, CAS prehospital from 2852 to 4013 with a 29% increase, CAS in-hospital from 3640 to 5662 with a 36% increase, Handgrip strength from 1814 to 3550 with a 49% increase, and 30s-STS from 2877 to 5083 with a 43% increase.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8079989/v1/274bdb3d5b56eac26bcd55af.png"},{"id":96364268,"identity":"7bcef45b-1fe5-4f3e-be5a-b444acb04805","added_by":"auto","created_at":"2025-11-20 10:09:08","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":211860,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eSurvey conducted in 2022 (70 physio and occupational therapists) and 2024 (69 physio and occupational therapists) with eight questions assessing physio and occupational therapists' experiences with the three tests implemented for evaluating basic physical function in hospital wards.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8079989/v1/3ae3657f113f404ab3c9a09c.jpeg"},{"id":102907297,"identity":"78e4c93a-753d-4b23-88c6-024d2e4ddd28","added_by":"auto","created_at":"2026-02-18 09:27:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":735472,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8079989/v1/e45612f0-9d6d-40e4-8c9f-0361d20643ba.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Implementation of Systematic Testing of Basic Physical Function in Hospitalized Adults","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePhysical function is a strong predictor of hospital length of stay, complications, readmission, and survival across a wide range of patients, regardless of diagnosis (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Despite this, physical function is rarely assessed systematically using validated tests in daily clinical practice, and if systematically assessed, it is typically limited to older patients. Parallel to the measurement of other organ functions, assessing physical function is a crucial parameter for evaluating and monitoring a patient's overall condition. For example, handgrip strength can be used as a vital sign, comparable to other vital signs such as heart rate, temperature, and respiratory rate (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eEarly detection of declining physical function is essential for the timely implementation of preventive and targeted interventions. Addressing the multiple challenges associated with physical frailty, and/or sarcopenia, is essential, especially as the prevalence of sarcopenia in Europe is expected to rise by more than 70% over the next 30 years (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Hospital service use is a major contributor to healthcare costs and expected to rise in Europe as the population ages (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Thereby routine systematic testing of basic physical function in hospitalized adult patients is vital for improving patient outcomes, enhancing healthcare quality and improve equality in treatment (\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTo be used systematically in clinical practice, tests of physical function need to be valid, easily applicable, and not too time consuming.\u003c/p\u003e\u003cp\u003eThe present implementation initiative chooses the following three tests that all adhere to these qualifications.\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eThe Cumulated Ambulation Score (CAS)(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e): Assesses patients' basic mobility defined as the ability to get in and out of bed, stand up and sit down in a chair with armrests, and walk with or without an assistive device with a one-day CAS score from 0\u0026ndash;6 points (0\u0026thinsp;=\u0026thinsp;bedridden and 6\u0026thinsp;=\u0026thinsp;able to ambulate independent of human assistance indoor). CAS is already widely implemented in hospital departments and municipalities as a simple and effective test for assessing patients in orthopaedic surgery (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), stroke (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), geriatrics (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), internal medicine (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), and gastrointestinal surgery (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eThe 30-seconds Sit-to-Stand Test (30s-STS): Assesses the number of chair stands the patient can complete in 30 seconds without using the arms and is a proxy measure for lower extremity muscle strength and function (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eHandgrip strength (HGS): Widely used as an indicator of overall muscle strength and is included in the European algorithm for sarcopenia assessment, with cut-off values set at 27 kg for men and 16 kg for women (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). HGS serves as a fundamental metric in assessing muscle function and overall physical capability and is particularly relevant to the ageing population. HGS is closely linked to sarcopenia, a condition characterized by the age-related decline in muscle mass, strength, and function (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). HGS has also proven to be a strong marker of functional decline and mortality, as a decrease in HGS over time is associated with disease profiles (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR22 CR23 CR24\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). This approach uses handgrip strength as an indicator of general muscle strength and is recognized internationally as a key measure in evaluating physical function, especially among older patients. The systematic assessment aims to support early identification of reduced physical function, enabling timely and targeted interventions during hospital stay(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eThe primary aim is to describe the implementation process, questionnaire surveys and audits conducted to assess the implementation of the 3 tests.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eDesign\u003c/strong\u003e\u003cp\u003eImplementation study. Equator network, STaRI and The Quality Implementation Framework (QIF) (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) has been used to structure the reporting in this paper.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eImplementation\u003c/b\u003e At the Department of Physical- and Occupational Therapy, Copenhagen University Hospital, Bispebjerg and Frederiksberg we implemented systematic testing of basic physical function across multiple departments and diagnosis. The hospital is one of the major acute university hospitals in the Copenhagen area with approximately 465 beds. The initiative\u003c/p\u003e\u003cp\u003einvolved Departments of Orthopedic Surgery, Neurology, Geriatrics, Respiratory disease, Abdominal surgery and Medicine, Cardiology and Emergency. This involved collaboration among hospital leadership, research- and implementation therapists, physiotherapist and occupational therapists (PTs and Ots), staff leaders, the patient journal system, and researchers. Dedicated project PTs and OTs ensured consistent calibration, supported by instructional videos, a dedicated homepage, and departmental presentations (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTo assess information from at staff, view questionnaire surveys were conducted in 2022 and 2024, assessing the PTs and OTs response to the systematic testing and to identify areas with a need for further focus in the ongoing process. In this first period of implementation, the systematic testing of physical function was implemented for patients referred to Physical- and/or Occupational Therapy for evaluation of their functional level from Orthopedic Surgery, Neurology, Geriatrics, Respiratory disease, Abdominal surgery and Medicine, Cardiology and Emergency.\u003c/p\u003e\u003cp\u003eThe implementation began by engaging key stakeholders and securing leadership support to establish structure, funding, and resources. A core implementation team, including clinical champions, was formed to ensure high staff involvement from the outset. Three simple, evidence-based physical function tests (bed mobility, transfer ability, ambulation) were selected for their relevance to both acute care and post-discharge planning (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Staff received targeted training, and regular feedback loops were used to monitor fidelity, address barriers across departments, and refine workflows.\u003c/p\u003e\u003cp\u003eThe integration of the three tests, illustrated in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, provides simple yet evidence-based assessment of physical function levels in hospitalized patients.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e, physical function. The initial evaluation and first mobilization attempt are conducted as early as possible after referral. Upon discharge or at the end of therapy, a final assessment is conducted to evaluate progress. Additionally, results of the three tests are reported in the rehabilitation plan forwarded to the municipal.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eTimeline for in-hospital use of the three tests of physical function\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTest / timepoints\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBefore admission\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInitial evaluation / first mobilisation attempt\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eInitial evaluation (if possible, otherwise the following days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eUpon discharge / end of therapy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ePlan for rehabilitation forwarded to the municipality\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCumulated Ambulation Score, 0\u0026ndash;6 point\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eX\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eX\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eX\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eX\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHandgrip strength, dominant hand, kg\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eX\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eX\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e30s \u0026ndash; Sit-To-Stand test, number of stand ups\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eX\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eX\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eX\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eQuestionnaire survey\u003c/strong\u003e\u003cp\u003eData were collected through eight target questions in 2022 and 2024 to assess progress and identify areas needing further attention. The implementation team group develop questions and used some background literature when designing the questions and considering what would be important to ask about (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Knowledge, Skills, Integration, Reasoning, Benefit, Prioritization, Automation, with answers given on a five-point Likert scale (Strongly agree, agree, neither agree nor disagree, disagree, strongly disagree) and for Self-efficacy on a numeric rating scale (0\u0026ndash;10, with 0 indicating no self-efficacy and 10 high self-efficacy) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The questions focused on various aspects of the implementation\u003c/p\u003e\u003c/p\u003e\u003cp\u003eKnowledge: I have knowledge of how to perform the tests and record them in the electronic patient journal. Skills: I have the practical skills to perform the tests and record the results in the electronic patient journal. Integration: I see performing the tests as a natural part of my work. Reasoning: Performing the tests and using the results contribute to my clinical reasoning. Benefit: Using the test results benefits the patients. Prioritization: I prioritize performing the functional tests even when I have other urgent. Automation: Performing the tests and using the results is something I do automatically. Self-efficacy: How confident are you that you will be able to functionally test all your patients next week, even if, for example, you are very busy, there is illness in the team, the patients are tired, etc.? (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eAudits\u003c/strong\u003e\u003cp\u003eMonthly data completeness audits were implemented from late 2022 through collaboration between the research department and therapist leaders across all departments. In early 2024, an additional audit evaluated whether physical function test results were properly documented in rehabilitation plans sent to municipal services at discharge. These audits assessed implementation effectiveness, including departmental test workflows, strategies to increase testing rates, documentation in patient records, and successful transfer of information to municipal rehabilitation plans.\u003c/p\u003e\u003c/p\u003e\u003cp\u003eThe number of tests performed was retrieved from the journal system by extracting data on all tests conducted across wards for 6 months from July to December in both 2022 and 2024. This approach provided an overview of the implementation strategy and its progression over time, allowing for an assessment of trends in test utilization and the direction of implementation efforts (se Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOverall, the implementation of the three tests improved from 2022 to 2024 with a marked increase in number of patients being tested with all three tests, see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e for details. Notably, HGS testing increased by 49%.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eResults and key deliverables\u003c/h3\u003e\n\u003cp\u003eThe implementation strategy was built on evidence from prior research and Danish cohort data, ensuring strong reference materials that aligned with hospital needs, available resources, and existing policies. Danish cohort studies provided evidence-based, age-decade and sex-specific reference values for the selected physical function tests, establishing a solid foundation for clinical decision-making. Full institutional support was secured from hospital leadership, ensuring alignment with organizational priorities and strategic goals. Hospital leadership and key organizational leaders were engaged from the project's inception to build institutional support and gather valuable feedback on implementation planning. Five multidisciplinary teams were established to oversee all aspects of planning, monitoring, and adaptation throughout the implementation process, ensuring comprehensive coverage across departments. Evidence-based algorithms and reference values were integrated, supported by instructional videos and standard operating procedures (SOPs) to ensure consistent testing protocols (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e for patient testing timeline). Financial and material resources were secured to support sustainability and ensure long-term integration of testing protocols into routine clinical workflows. Staff received thorough training through multiple modalities, including instructional videos (available at \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003ca href=\"http://www.BBH.fysisk-funktion.dk\" target=\"_blank\"\u003ewww.BBH.fysisk-funktion.dk\u003c/a\u003e\u003c/span\u003e\u003cspan address=\"http://www.BBH.fysisk-funktion.dk\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e), written SOPs, and department-wide presentations to ensure testing fidelity across all clinical areas. Implementation staff conducted presentations and facilitated discussions during departmental staff meetings. Additionally, experienced scientists participated in selected patient testing sessions to identify barriers and discuss solutions for integrating assessments into daily practice. Regular coaching, technical assistance, and workshops were provided to maintain implementation quality and address emerging challenges. Systematic progress tracking and feedback collection enabled adaptations and continuous improvement throughout the implementation process. Implementation challenges were systematically identified and addressed through twice-monthly local group meetings (medical ward, stroke unit, musculoskeletal ward) and monthly leadership meetings for ongoing evaluation. Common barriers including variations in staff engagement and perceived meaningfulness of the tests were actively addressed through targeted interventions and ongoing dialogue with clinical teams.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults of survey, audit and performance monitoring.\u003c/b\u003e\u003c/p\u003e\u003cp\u003ePTs and OTs demonstrated a well-established knowledge base and possessed the necessary skills to effectively conduct the three tests in both 2022 and 2024. Notably, there was a slight improvement in their skills in 2024 compared to 2022. This progression suggests ongoing development and refinement of their expertise over time (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe integration and reasoning aligned with the strategy were observed in only about 50% of the PTs and OTs responses. This pattern was consistent across both the 2022 and 2024 data, indicating that while some PTs and OTs incorporate strategic reasoning in their use of the three tests, a significant portion does not fully integrate it (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), illustrating integration and reasoning. Approximately 50% of PTs and OTs do not fully recognize how the strategy can benefit one-on-one patient treatment, and this trend remains consistent in 2024 (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn terms of prioritization, the responses were notably divided. Around half of the PTs and OTs express, either agreement or strong agreement with the prioritization approach, while the other half showed a contrasting viewpoint, disagreement or strong disagreement. This division highlights a significant variation in how PTs and OTs perceive and approach prioritization, suggesting that there are diverse perspectives and possibly differing interpretations or experiences with the strategy in practice (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). About half of the responders do not view the three tests as something they do automatically. However, there is a slight improvement in 2024, with more respondents agreeing or strongly agreeing that using the test and the results are something they do automatically. This indicates a shift toward the perception of the tests being integrated into everyday practice (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe last question, which concerns PTs and OTs self-efficacy in testing patients next week despite potential scheduling challenges and a busy calendar, revealed that approximately half of the PTs and OTs were confident they could conduct the tests. This self-efficacy shows a slight improvement in 2024, with a greater number of PTs and OTs expressing certainty that they will be able to perform the tests. This trend suggests that, over time, PTs and OTs have become more confident in managing their schedules and prioritizing the necessary tests, even in the face of competing demands (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The implementation of systematic testing for basic physical function in hospitalized adults was found to be good regarding PTs and OTs describing good overall knowledge and skills necessary for the systematic testing in the clinic. However, nearly 50% of PTs and OTs reported difficulties in recognizing the direct benefit of the tests during one-to-one patient interactions.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThroughout the implementation period, no adverse events were reported in relation to either the implementation strategy activities (training, coaching, audits) or the administration of the three physical function tests (CAS, 30s-STS, handgrip strength). The implementation process and testing procedures were well-tolerated by both healthcare staff and patients.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe systematic implementation of physical function testing across hospital wards and diagnoses has been successful, demonstrating significant progress in increasing the number of patients tested - a primary goal of the initial implementation phase.\u003c/p\u003e\u003cp\u003eThe data from surveys conducted in 2022 and 2024 indicates a positive trend in PTs and OTs competence and self-efficacy regarding the three tests (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Also, data from 2022 to 2024 showed an increasing number of patients being evaluated using the three tests. However, several areas seem to require further and ongoing attention and close connections to leadership and implementation team to ensure the sustainability and integration of these practices into everyday hospital routines. Enhancing staff coherence and addressing concerns about the perceived meaningfulness of the testing emerged as key areas for improvement. These findings suggest that additional efforts may be needed to integrate the testing more effectively into clinical practice and to highlight its value in patient care and sector transitions.\u003c/p\u003e\u003cp\u003eWhat worked well!\u003c/p\u003e\u003cp\u003eA very important goal in the first years of implementation was to reach complete data and that more and more patients were tested, this worked well across departments and was very successful overall.\u003c/p\u003e\u003cp\u003eThe development and application of the implementation strategy were largely successful. The comprehensive approach, built upon prior evidence and Danish cohort data, ensured that the selected tests were well-suited to the hospital context and the needs of the patients. The engagement of key stakeholders, particularly hospital leadership, was critical to aligning the initiative with institutional priorities and securing the necessary resources for long-term success. The formation of multidisciplinary implementation teams, supported by training courses, instructional videos, and standard operating procedures (SOPs), ensured a consistent application of the tests across different wards. Training and continuous support, such as coaching and workshops, were instrumental in maintaining the quality of the implementation. PTs and OTs demonstrated well-established knowledge and skills in 2022, with slight improvements noted in 2024. This ongoing development highlights the success of the structured training and support provided to staff. The engagement with stakeholders and the availability of clear instructional materials contributed to high levels of participation and enthusiasm for the implementation. The increase in tests performed between 2022 and 2024 indicates a notable improvement in the implementation strategy, reflecting enhanced engagement and adherence. HGS testing demonstrated a substantial rise, suggesting a greater focus on assessing muscle function and ease of test. This increase may be attributed to improved awareness, streamlined procedures, or greater accessibility of testing and available HGS devices. These results highlight the effectiveness of the implementation strategy and underscore the potential for further optimizing screening efforts in clinical settings.\u003c/p\u003e\u003cp\u003eAreas for improvement\u003c/p\u003e\u003cp\u003eDespite these successes, some challenges remain. One notable finding was that approximately 50% of PTs and OTs did not see the direct benefit of the tests in one-on-one patient treatment. This suggests that while the tests are being administered, the broader value of integrating test results into routine care is not yet fully perceived by a significant portion of the clinical staff. This issue remained consistent across both in the 2022 and 2024 surveys, signaling the need for further efforts to communicate the strategic importance of the tests and their direct impact on patient care. A possible approach to addressing the issue would be to establish specialty-specific clinical reference values - such as psychometric indicators like MDC, MCID, and related metrics - that therapists can integrate into the goal-setting process and clinical reasoning to enhance the precision and measurability of therapeutic goals and rehabilitation efforts. Similarly, responses regarding the prioritization of the tests were divided, with PTs and OTs offering a wide range of perspectives. Half of the PTs and OTs agreed with the prioritization approach, while the other half disagreed. This division points to the varied perceptions of how the tests should fit into the broader clinical workflow. Future efforts should focus on clarifying the role of these tests in patient care and aligning the team on their importance to ensure more uniform support and prioritization.\u003c/p\u003e\u003cp\u003eAnother area for improvement relates to the automation of using the tests. While there was some progress between 2022 and 2024, with more PTs and OTs acknowledging that they automatically conduct the tests, approximately half of the respondents still do not view the tests as part of their daily routine. This suggests that while the tests are becoming more integrated into clinical practice, full automation and routine application have not yet been achieved. Continued efforts to embed these tests into the daily workflow and ensure that they are seen as an integral part of patient care are necessary.\u003c/p\u003e\u003cp\u003ePositively, the PTs and OTs self-efficacy in performing the tests despite busy schedules and potential scheduling challenges improved slightly between 2022 and 2024. This trend suggests that PTs and OTs are becoming more confident in managing their time and prioritizing these tests. However, the need for sustained improvement in this area remains, as a portion of PTs and OTs still express uncertainty about their ability to conduct the tests in the face of competing clinical responsibilities. In a similar implementation study by Ibrahim et al (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) it was shown that implementing routine grip strength measurement by training a large cohort of nurses was feasible, acceptable, and cost-effective in hospital settings. The key factors supporting successful uptake included strong motivation from ward champions, clear managerial backing, and a shared commitment among staff. The process enabled the identification of a high proportion of older patients at risk of adverse health outcomes and created opportunities to fast-track patients with normal strength from admission to discharge, potentially reducing hospital length of stay.\u003c/p\u003e\u003cp\u003eUsing three validated tests in this present implementation will increase identification of patients at risk of adverse advents.\u003c/p\u003e\u003cp\u003eThe strategy moving forward.\u003c/p\u003e\u003cp\u003eThe implementation of physical function testing in hospital settings requires a comprehensive and adaptive strategy (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). The mixed responses on prioritization, perceived benefit, and automation highlight that further efforts are needed to enhance staff engagement and increase the meaningfulness of the tests in the eyes of PTs and OTs .The structured training and the provision of resources such as instructional videos and SOPs have been effective, but additional strategies are needed to reinforce the relevance of the tests and ensure their full integration into clinical practice.\u003c/p\u003e\u003cp\u003eMoving forward, the continued application of frameworks such as the Quality Implementation Framework (QIF), the PDSA (Plan-Do-Study-Act) cycle and Knowledge-To-Action (KTA) model (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) will be essential to refine the implementation strategy (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). These frameworks will allow for ongoing assessment and adaptation, ensuring that challenges are identified and addressed in real time. Continuous feedback from PTs and OTs will be vital in understanding the barriers to full adoption and ensuring that the tests are not only conducted but are seen as an integral part of patient care.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe introduction of systematic physical function testing in hospital wards from 2022 to 2024 improved PT and OT knowledge, skills, and perceived? self-efficacy. The structured, evidence-based approach increased testing rates - especially for handgrip strength - and made these assessments more routine. However, only about half of clinicians see clear patient benefits, and some still question the tests’ priority and automation. While technical competence and self-efficacy under time pressure have grown, full integration into daily practice remains incomplete.\u003c/p\u003e\n\n"},{"header":"Perspectives","content":"\u003cp\u003eInsights from the 2022 and 2024 surveys are vital for refining strategies, as they highlight staff experiences and operational barriers with physical function testing. Integrating survey feedback will help address persistent issues. Tailored interventions and training can then target these gaps. Empowering local champions within clinical teams is also key to driving engagement and cultural change.\u003c/p\u003e\u003cp\u003eDatasets generated in the present study are not publicly accessible due to Danish data sharing agreements but may be obtained from the corresponding author upon reasonable request. The study was conducted in accordance with the Declaration of Helsinki and approved by the local Danish ethical committee (2301–6039).\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics, Consent to Participate, and Consent to Publish declarations: not applicable.\u003c/p\u003e\u003cp\u003eClinical trial number: not applicable\u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e\u003cp\u003eDanish Physiotherapy Association and the Department of Physio- and Occupational Therapy Bispebjerg Hospital, Copenhagen, Denmark.\u003c/p\u003e\u003cp\u003eAuthor statements. We have no Conflict of Interest\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAuthor contributions: CHD, MAA, CS, and MTK conceived and designed the work; CHD, CKM, CHA, TB, NMH, MAA, CS, and MTD contributed to data acquisition, analysis, and interpretation; all authors have substantially revised the manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eDatasets generated in the present study are not publicly accessible due to Danish data sharing agreements but may be obtained from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eScheerman K, Meskers CGM, Verlaan S, Maier AB, Sarcopenia. Low Handgrip Strength, and Low Absolute Muscle Mass Predict Long-Term Mortality in Older Hospitalized Patients: An Observational Inception Cohort Study. J Am Med Dir Assoc. 2021;22(4):816\u0026ndash;e202.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWitt LJ, Spacht WA, Carey KA, Arora VM, White SR, Huisingh-Scheetz M, et al. Weak Handgrip at Index Admission for Acute Exacerbation of COPD Predicts All-Cause 30-Day Readmission. Front Med (Lausanne). 2021;8:611989.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLi CY, Haas A, Pritchard KT, Karmarkar A, Kuo YF, Hreha K, et al. Functional Status Across Post-Acute Settings is Associated With 30-Day and 90-Day Hospital Readmissions. J Am Med Dir Assoc. 2021;22(12):2447\u0026ndash;e535.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVaishya R, Misra A, Vaish A, Ursino N, D'Ambrosi R. Hand grip strength as a proposed new vital sign of health: a narrative review of evidences. J Health Popul Nutr. 2024;43(1):7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEthgen O, Beaudart C, Buckinx F, Bruy\u0026egrave;re O, Reginster JY. The Future Prevalence of Sarcopenia in Europe: A Claim for Public Health Action. Calcif Tissue Int. 2017;100(3):229\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSirven N, Rapp T. The Dynamics of Hospital Use among Older People Evidence for Europe Using SHARE Data. Health Serv Res. 2017;52(3):1168\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGallardo-G\u0026oacute;mez D, Del Pozo-Cruz J, Pedder H, Alfonso-Rosa RM, \u0026Aacute;lvarez-Barbosa F, Noetel M, et al. Optimal dose and type of physical activity to improve functional capacity and minimise adverse events in acutely hospitalised older adults: a systematic review with dose-response network meta-analysis of randomised controlled trials. Br J Sports Med. 2023;57(19):1272\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKrumholz HM. Post-hospital syndrome\u0026ndash;an acquired, transient condition of generalized risk. 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High intertester reliability of the cumulated ambulation score for the evaluation of basic mobility in patients with hip fracture. Clin Rehabil. 2009;23(12):1116\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKristensen MT, \u0026Ouml;zt\u0026uuml;rk B, R\u0026ouml;ck ND, Ingeman A, Palm H, Pedersen AB. Regaining pre-fracture basic mobility status after hip fracture and association with post-discharge mortality and readmission-a nationwide register study in Denmark. Age Ageing. 2019;48(2):278\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eArens CH, Johnsen NM, Milanesi M, Weli A, Linnebjerg C, Christensen H, et al. Inter-tester reliability and agreement of the Cumulated Ambulation Score in acute stroke: The InTRO-CAS-stroke study. J Stroke Cerebrovasc Dis. 2024;33(5):107630.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAagesen M, Kristensen MT, Vinther A. 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Jt Comm J Qual Improv. 1996;22(3):206\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Systematic Testing, Physical Function, Hospitalized Patients, Healthcare Staff Evaluation, Implementation","lastPublishedDoi":"10.21203/rs.3.rs-8079989/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8079989/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eAssessing physical function in hospitalized adult patients is considered important for early detection of functional decline, for improving patient outcomes, and enhancing healthcare quality. However, systematic assessment of physical function is rarely done, and if so, only in older patients. New strategies for systematic testing of physical function to detect signs of functional decline in all adult patients are therefore warranted. The aim was to implement three basic physical function tests across hospital departments and various diagnoses.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eImplementation study describing deliverables, activities and survey data among 125 physio- and occupational therapists (PT and OT in 2022 and 2024, monthly audits of patient journals and rehabilitation plans, and number of tests performed, extracted from journal systems. Setting: Major acute university hospital. Three validated tests: the Cumulated Ambulation Score as a measure of basic mobility. The 30-seconds Sit-to-Stand Test and Handgrip strength.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe number of tests performed improved by 36% from 2022 to 2024. The surveys demonstrated that skills and knowledge were well established. Still, PT and OT reported lack of meaningfulness in their clinical reasoning and failure to see the benefit for the patients regarding the implementation of the 3 tests. While some components were well accepted by staff, others require further development based on key questionnaire findings.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eOverall, the first two years of implementation were successful with a marked increase of 36% in number of tests performed. The PT and OT were well-calibrated and actively engaged in testing, although challenge for the therapists to incorporate test results into clinical reasoning and goal setting together with the other findings.\u003c/p\u003e","manuscriptTitle":"Implementation of Systematic Testing of Basic Physical Function in Hospitalized Adults","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-19 12:13:30","doi":"10.21203/rs.3.rs-8079989/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a9d92597-5f11-4f92-966b-d239a2f810f1","owner":[],"postedDate":"November 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-18T09:25:58+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-19 12:13:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8079989","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8079989","identity":"rs-8079989","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}