David Oliver: Fighting pyjama paralysis in hospital wards

The momentum of Nottingham University Hospitals’ social media campaign “End PJ Paralysis” has been growing,1 with clinical teams around the country joining in and reports appearing in the national media.2

Its starting premise is that we should get more hospital inpatients out of nightwear, out of bed, and into their day clothes to speed their recovery and help minimise harms from prolonged immobility.

The perils of bed rest as treatment for hospital inpatients were recognised in the 1940s by Richard Asher, in his seminal essay The Dangers of Going to Bed,3 and they were elegantly reviewed by Allen and colleagues years later.4 Marjory Warren, the mother of UK geriatric medicine and Asher’s contemporary, described in a series of papers the benefits for patients and for hospital bed utilisation of getting “infirm and bedridden” people out of bed and on their feet.56

The kind of long stay inpatient wards Warren described no longer exist. And rapid increases in hospital admission numbers, mirrored in scale by reductions in beds, mean that patients who might formerly have been halfway down an old-style Nightingale ward are now long since discharged home. Beyond some fracture management, bed rest as a prescribed treatment is rare.

However, excessive bed rest is still all too familiar. These days it’s more likely to be an inadvertent by-product of competing pressures on a depleted nursing workforce,7 compounded by variable availability of physiotherapists, occupational therapists, and their assistants.89 Getting people up and dressed and being more independent can fall down the pecking order.

These days, bed rest is likely to be a by-product of competing pressures on a depleted nursing workforce

The median age of inpatients is rising, with pre-existing mobility impairment prevalent on admission.10 Even in wards geared up for post-acute rehabilitation, many patients leave much less mobile than they were before the acute episode that led to their admission.1112 Even a few days’ bed rest can cause rapid decline in muscle strength and aerobic capacity, especially in patients with pre-existing sarcopenia.13

Other harms of bed rest include higher risk of thrombosis or delirium, pressure sores, infection or contractures, loss of confidence, and greater dependence.14 It can also cause incontinence by too often resorting to catheters, pads, or bedpans or by causing constipation, instead of assisting and encouraging patients to toilet as they usually would.15 Bed rails can compound the problem, and evidence for their use is poor.16

Whenever possible we should divert more patients to ambulatory care and away from beds. As for the others, we need to stop reflexively putting them into flapping-open gowns and pyjamas. And, if on a ward round we see patients still in bed in nightclothes with bed rails up, it’s the responsibility of everyone in the ward team to challenge and change this.