Reducing Effects of Hospital-Associated Deconditioning in Patients Undergoing Allogeneic Hematopoietic Stem Cell Transplantation

Abstract

Prolonged hospitalization and treatment-related toxicities increase the risks of immobility and decreased functional status in patients undergoing allogeneic hematopoietic stem cell transplantation (allo HSCT). This quality improvement project evaluated whether targeted education and access to a stationary elliptical bike (SEB) could reduce hospital-associated deconditioning in 106 adult patients undergoing allo HSCT. Using the Karnofsky Performance Status Scale, findings suggest that SEBs are a safe and feasible approach for preserving functional status during prolonged hospitalization in patients undergoing allo HSCT.

AT A GLANCE

• ■ Patient education and access to SEBs during hospitalization for allo HSCT helps preserve functional status and independence.

• ■ SEBs are a safe and feasible exercise option for hospitalized patients undergoing allo HSCT.

• ■ Encouraging early mobility through structured exercise may reduce the risk of hospital- associated deconditioning, supporting recovery.

Allogeneic hematopoietic stem cell transplantation (allo HSCT) remains the only curative option for a variety of hematologic malignancies. However, allo HSCT is associated with prolonged hospitalization, functional decline, and an increased risk of morbidity and mortality (Borsati et al., 2025). Many patients undergoing allo HSCT are hospitalized for a minimum of four to six weeks, secondary to rigorous chemotherapy regimens and concomitant toxicities. Chemotherapy treatment paired with the subsequent suppressed bone marrow increases the risk of mucositis, nausea, diarrhea, decreased appetite, bleeding, infection, weakness, and fatigue, contributing to the risk of hospital-associated deconditioning (HAD) (Morishita et al., 2019).

HAD is a reduction in functional performance following hospitalization, negatively affecting a patient’s quality of life and ability to function independently (Chen et al., 2022). Prolonged immobility is closely linked to decreased muscle strength, decline in physical function, and a reduced capacity to independently perform activities of daily living. A study by Kim et al. (2022) revealed that acute medical settings discharge 68% of patients with a lower functional status compared to admission, and that this decline is caused by factors such as immobility, disrupted sleep, and poor nutrition.

Older adults with cancer are at greater risk for HAD because of their underlying disease and associated therapies. Evidence supports that exercise during cancer treatment is safe, even in vulnerable populations (Mercer, 2020; Schmitz et al., 2019). For patients undergoing allo HSCT, early rehabilitation has been associated with shorter hospital stays and improved recovery, which reduce resource utilization at discharge (Hamada et al., 2022).

Tavoian et al. (2021) identified that stationary elliptical bikes are effective in improving cardiovascular function with a relatively low risk of injury in hospitalized patients, particularly patients aged older than 70 years. Incorporating stationary elliptical bike exercise into daily physical activity has a positive impact on functional status, increasing muscle strength and improving gait and balance, which in turn reduces the risk of HAD (Mosser et al., 2025).

Moffitt Cancer Center, a seven-site National Cancer Institute–designated comprehensive cancer center in Tampa, Florida, performs nearly 400 HSCTs annually. The cancer center identified HAD as a significant concern in hospitalized patients undergoing allo HSCT, including deficits in basic self-care, loss of functional independence, delayed return to baseline performance status, disruption in occupational and societal roles, and increased need for external social support. These issues collectively diminish the patient’s quality of life following transplantation, regardless of disease status or post-HSCT complications. In response, an interprofessional team implemented a quality improvement (QI) project to address HAD through education and by promoting stationary elliptical bike use during hospitalization to reduce weakness and physical deconditioning.

Methods

The QI project team, comprising physicians, advanced practice providers, physical therapists, RNs, and clinical nurse specialists, used the Plan-Do-Study-Act model to guide implementation (Institute for Healthcare Improvement, n.d.). The team assessed functional status using the Karnofsky Performance Status Scale (KPS), a validated tool that predicts treatment tolerance and outcomes. KPS scores range from 0 (death) to 100 (normal function), with higher scores indicating greater independence in daily activities and lower scores reflecting increasing levels of disability or need for assistance (Péus et al., 2013). The QI project’s primary outcome was functional mobility and the degree of reduction in KPS scores, defined as the change in KPS scores from preadmission to discharge. Secondary outcomes included length of hospitalization in days, incidence of patient falls, and physical therapy recommendations upon discharge. The QI project team manually reviewed the preadmission and discharge KPS scores, length of inpatient stays, incidence of patient falls, and physical therapy discharge recommendations through the electronic health record.

All adult patients aged 18–80 years admitted to the 32-bed inpatient bone marrow transplantation unit for allo HSCT between December 1, 2023, and March 1, 2024, were included in the postintervention group. The team identified a preintervention group, consisting of patients who underwent allo HSCT prior to installing stationary elliptical bikes and did not receive the targeted patient education intervention (July 1 to October 1, 2023).

The QI project team collected baseline clinical and demographic data from the electronic health record, including age, race and ethnicity, gender, donor source, conditioning regimen, and graft-versus-host disease prophylaxis regimen. Death during hospitalization for allo HSCT was an exclusion. Factors such as mechanical ventilation, continuous renal replacement therapy, and severe transplant-related toxicities are known to contribute to HAD; however, the QI project team was unable to reliably identify their specific impacts on patient outcomes within the scope of this analysis.

The QI project team used descriptive statistics to compare patients who received the intervention (targeted education and access to stationary elliptical bikes) to those who did not. Nonparametric statistical methods were applied to assess demographic and clinical characteristics using univariate models, including Mann–Whitney U, Fisher’s exact, and Pearson’s chi-square tests. Statistical analyses were conducted using RStudio software. The team obtained institutional review board exemption, and patient education specialists in the nursing professional development department approved the hospitalwide distribution of patient education.

Interventions

The intervention included the following two components: (a) specific patient education and (b) access to a stationary elliptical bike. Beginning December 1, 2023, patients received printed educational materials in English or Spanish, which included information about HAD (see Figure 1), safety guidance, and stationary elliptical bike instructions. The organization installed two stationary elliptical bikes in the bone marrow transplantation unit hallway for voluntary use. The QI team informed physicians, advanced practice providers, RNs, oncology technicians, and physical therapists of the initiative and encouraged them to promote stationary elliptical bike use as an alternative exercise option to ambulation or under-desk pedal bikes. The project coordinator regularly reinforced exercise instructions and answered questions from patients, caregivers, and staff. RNs and physical therapists documented patient mobility throughout the day within the electronic health record.

FIGURE 1.

HOSPITAL-ASSOCIATED DECONDITIONING IN PATIENTS UNDERGOING STEM CELL TRANSPLANTATION EDUCATION SHEET

To encourage participation, the nursing staff independently developed a unit-based incentive program to complement the project. The hallway featured a large map of the Tampa region, and staff assigned a numbered bike marker to each patient’s room. As patients biked miles, they advanced their markers along the map to visually track progress.

Results

A total of 106 patients participated in the three-month project, with 45 (42%) in the postintervention group and 61 (58%) in the preintervention group. Patients had a mean age of 61 years (range = 21–80). There were 65 (61%) male patients, and 90 (85%) identified as White. Overall, 75 patients (71%) received reduced intensity conditioning chemotherapy, and 51 (48%) underwent allo HSCT for acute myeloid leukemia. Donor sources included 68 (64%) matched unrelated donors, 12 (11%) mismatched unrelated donors, 10 (9%) matched sibling donors, and 16 (15%) haploidentical donors. Graft-versus-host-disease prophylaxis varied, with 59 patients (56%) receiving post-transplant cyclophosphamide with tacrolimus and mycophenolate mofetil. Clinical characteristics were comparable between groups. Table 1 includes all sample descriptive statistics.

TABLE 1.

DESCRIPTIVE STATISTICS

CHARACTERISTIC	OVERALL (N = 106)		PRE (N = 61)		POST (N = 45)		p
	X̄	RANGE	X̄	RANGE	X̄	RANGE
Age (years)	61	21–80	64	22–80	59	21–77	0.13a
Baseline KPS score	90	70–100	90	70–100	90	70–100	–
Change in KPS score during hospitalization	10	0–70	10	0–70	10	0–20	0.74a
Discharge KPS score	80	0–90	70	0–90	80	60–90	–
Length of hospitalization (days)	23.5	12–70	24	18–67	23	12–70	0.75a
CHARACTERISTIC	n	%	n	%	n	%	p
Gender							0.69b
Male	65	61	36	59	29	64
Female	41	39	25	41	16	36
Race							0.28c
Black	9	8	5	8	2	4
Hispanic	3	3	2	3	–	–
White	90	85	52	85	41	91
Other	4	4	2	3	2	4
Diagnosis							0.91c
Acute lymphoblastic leukemia	10	9	5	8	5	11
Acute myeloid leukemia	51	48	29	48	22	49
Myelodysplastic syndrome or myeloproliferative neoplasm	29	27	17	28	12	27
Lymphoma	15	14	9	15	6	13
Other	1	1	1	2	–	–
Conditioning intensity							0.28b
Myeloablative	31	29	15	25	16	36
Reduced intensity	75	71	46	75	29	64
Donor source							0.14c
Matched unrelated donor	68	64	42	69	26	58
Mismatched unrelated donor	12	11	4	7	8	18
Matched sibling donor	10	9	4	7	6	13
Haploidentical	16	15	11	18	5	11
Graft-versus-host-disease prophylaxis							0.21c
PTCy/sirolimus/MMF	20	19	12	20	8	18
PTCy/tacrolimus/MMF	59	56	34	56	25	56
Tacrolimus/methotrexate	7	7	3	5	4	9
Tacrolimus/methotrexate/abatacept	13	12	7	11	6	13
Other	7	7	5	8	2	4
Baseline KPS score							0.2c
100	14	13	5	8	9	20
90	62	58	35	57	27	60
80	27	25	19	31	8	18
70	3	3	2	3	1	2
Discharge KPS score							0.34c
90	17	16	9	15	8	18
80	37	35	16	26	21	47
70	38	36	25	41	13	29
60	10	9	7	11	3	7
50 or less	4	4	4	7	–	–
Inpatient falls							1b
No	105	99	60	98	45	100
Yes	1	1	1	2	–	–
Discharge PT recommendations							0.4c
Home PT	7	7	3	5	4	9
Outpatient rehabilitation	12	11	9	15	3	7
Skilled nursing facility	1	1	1	2	–	–
Independent	86	81	48	79	38	84

^aMann–Whitney U test

^bFisher’s exact test

^cPearson’s chi-square test

KPS—Karnofsky Performance Status Scale; MMF—mycophenolate mofetil; post—postintervention; pre—preintervention; PT—physical therapy; PTCy—post-transplantation cyclophosphamide

Note. Because of rounding, percentages may not total 100.

Note. No patients received inpatient rehabilitation PT recommendations.

The baseline KPS scores were similar across groups, with a median score of 90 (range = 70–100). A higher proportion of patients (n = 36, 80%) in the postintervention group had a baseline KPS score of 90–100 compared to the preintervention group (n = 40, 65%). Three patients (2 preintervention versus 1 postintervention) had a baseline KPS score of 70, which is the minimum KPS score to be eligible for allo HSCT, according to the institutional standard of care (see Figure 2).

FIGURE 2.

CHANGE IN KARNOFSKY PERFORMANCE STATUS SCALE SCORE FROM PREADMISSION TO DISCHARGE, STRATIFIED BY GROUP

The median degree of change in KPS score from preadmission to discharge was 10 points in both groups (range = 0–70, p = 0.74). The median discharge KPS score was higher in the postintervention group (80, range = 60–90) than in the preintervention group (70, range = 0–90). There were 11 patients in the preintervention group who had a discharge KPS score below 60 compared to three patients in the postintervention group (p = 0.34). Four patients in the preintervention group had a discharge KPS score below 50, compared to none in the postintervention group (p = 0.34). No patients in either group showed improvement in KPS scores from preadmission to discharge.

In addition to the primary outcome, there were no statistically significant differences in secondary outcomes. Most patients were discharged as independent, and discharge physical therapy recommendations were similar between the groups (n = 48, 79% preintervention versus n = 38, 84% postintervention, p = 0.4). The preintervention group referred one patient to a skilled nursing facility, and neither group referred any patients for inpatient rehabilitation. The median length of hospitalization was similar between groups, with the preintervention group at 24 days (range = 18–67) and the postintervention group at 23 days (range = 12–70, p = 0.75). The postintervention group recorded no falls, and the preintervention group experienced one fall (p = 1).

Discussion

These real-world findings demonstrate the safety and feasibility of patient education and stationary elliptical bike use in maintaining functional status in patients undergoing allo HSCT. This aligns with prior studies highlighting the impact of HAD and the role of early mobility interventions in improving patient outcomes during prolonged hospitalization (Aronson et al., 2023; Morishita et al., 2019). Although differences in outcomes were not statistically significant (as expected in a small-scale QI project), the team observed several clinically meaningful advantages. In the postintervention group, there were no patients with a discharge KPS score below 60, and a greater proportion of patients had a discharge KPS score above 80. In addition, there were no recorded falls in the postintervention group, no physical therapy recommendations for inpatient rehabilitation or at a skilled nursing facility, and no bike-related injuries or adverse events recorded. These findings suggest that the intervention is safe and practical for this high-risk patient population, adding to the growing literature supporting mobility preservation strategies in oncology and transplantation settings.

Limitations

Limitations included the small sample size and short project duration, limiting the generalizability of the findings to the broader patient population and precluding long-term follow-up for sustainability. Although the KPS score is a validated and widely used tool, its subjective nature and limited sensitivity to subtle or short-term changes may result in an underestimation of the intervention’s full impact. Data on the frequency and duration of stationary elliptical bike use were not available during the statistical analysis, hindering the ability to verify adherence. In addition, unmeasured confounding factors may have influenced outcomes, making it challenging to isolate the effects of the intervention alone.

Implications for Nursing

This QI project highlights a practical, nurse-driven strategy to address HAD in patients undergoing allo HSCT. Oncology nurses promote safe physical activity during hospitalization, and this project demonstrates how simple interventions, such as structured patient education and access to exercise alternatives, can be integrated into daily practice. By encouraging and supporting mobility, nurses can help to reduce functional decline, minimize the need for postdischarge rehabilitation services, and improve patient outcomes. This intervention is adaptable to other inpatient oncology settings. More research and replication projects can help determine the impact on quality of care for patients with cancer.

Conclusion

Allo HSCT remains the only curative option for a variety of hematologic malignancies. The rigorous chemotherapy regimens and associated toxicities of HSCT often lead to prolonged hospitalization, increasing the risk of immobility and decreased functional status. The findings of this QI project suggest that providing patient education and access to stationary elliptical bikes may help to maintain functional status and enhance safety in patients undergoing allo HSCT. Additional investigation is warranted to identify optimal strategies for enhancing patient knowledge and preserving mobility during hospitalization. Proactively addressing HAD through targeted interventions can improve patient outcomes in this high-risk population.

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