Early Mobilization of Patients Hospitalized With Community-Acquired Pneumonia

doi:10.1378/chest.124.3.883

Chest

Volume 124, Issue 3, September 2003, Pages 883-889

https://doi.org/10.1378/chest.124.3.883 Get rights and content

Study objective:

To determine if early mobilization (EM) of hospitalized adults with community-acquired pneumonia (CAP) reduces hospital length of stay.

Design:

Group randomized trial.

Setting:

Three Midwestern hospitals.

Participants:

Four hundred fifty-eight patients with CAP admitted to 17 general medical units between November 1997 and April 1998.

Intervention:

EM was defined as sitting out of bed or ambulating for at least 20 min during the first 24 h of hospitalization. Progressive mobilization occurred each subsequent day during hospitalization.

Measurements and results:

Intervention (n = 227) and usual-care patients (n = 231) were similar in age, gender, disease severity, door-to-drug delivery time, and IV-to-po switchover time. Hospital length of stay for EM vs usual care was significantly less (mean, 5.8 vs 6.9 days; adjusted absolute difference, 1.1 days; 95% confidence interval, 0.0 to 2.2 days). There were no differences in adverse events or other secondary outcomes between treatment groups.

Conclusions:

Like patients hospitalized with acute myocardial infarction and total knee replacements, EM of hospitalized patients with CAP reduces overall hospital length of stay and institutional resources without increasing the risk of adverse outcomes.

Section snippets

Protocol

The study population included patients with CAP admitted to three hospitals in St. Louis, MO from November 17, 1997, through April 30, 1998. Inclusion criteria were ≥ 18 years old, new infiltrate on chest radiograph (compared with old radiographs if available), and either one major criteria (cough, sputum production, or temperature > 37.8°C) or two minor criteria (pleuritic chest pain, dyspnea, altered mental status, pulmonary consolidation on examination, or leukocyte count > 12,000/μL).¹²^,¹³

Patients

Four hundred fifty-eight of 711 patients (64%) hospitalized with CAP were included in the study. Patient exclusions were hospitalization within 2 weeks of the current hospital admission (n = 190), diagnosis with large-volume aspiration pneumonia (n = 31), admission or transfer to an ICU (n = 17), or assignment to a nonstudy hospital unit (n = 15). Of the 458 patients enrolled, 428 patients (93%) met the major criteria and 30 patients (7%) met the minor criteria for definitive or presumptive

Discussion

Our data suggest that EM of patients with CAP with movement out of bed for at least 20 min during the first 24 h of hospitalization and progressive daily mobilization can reduce hospital length of stay without increasing risk of adverse outcomes. Although this intervention has been shown to be effective for other disease entities,¹⁰^,¹¹ EM is not recommended in CAP care nor is it a therapeutic component of current CAP guideline recommendations.²⁰^,²¹ We did not observe a dose-response

ACKNOWLEDGMENT

We thank the patients, families, nurses, and administrators at Barnes-Jewish Hospital, Christian Hospital Northeast and Missouri Baptist Medical Center for their participation and support. We thank Vicki Ferris, Neice Green, Naomi Hampton, JoAnn Johnson, Krista Kuhn, Barb Quick, Cindy Spies and Lynn Williams for data collection; Debbie Geiselman, Judy Musick, and Connie Sinn for data management; Jennie Dulac for administrative support; and Jordana Stewart for manuscript preparation.

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Management of Non-Ventilated hospital acquired pneumonia
2024, Clinical Infection in Practice
Non-ventilated hospital acquired pneumonia (NV-HAP) is defined as pneumonia that develops at least 48 h after hospital admission in the non-invasively ventilated patient. Guidance in the management of NV-HAP has historically used extrapolated research from the wider field of HAP, which includes patients with the separate clinical entity of ventilator associated pneumonia (VAP), or the field of community acquired pneumonia (CAP). However, NV-HAP is being increasingly recognised as a subtype of HAP owing to its high incidence, mortality, morbidity and health-economic burden. With a wide range of underlying causative organisms, the management approach focuses on initial broad-spectrum coverage of common bacterial pathogens. If microbiological results are available, targeted treatment can be started. Throughout all phases of treatment, supportive measures must also be considered. This includes the use of physiotherapy, oxygen and ventilatory support, fluid therapy and nutritional support. Research is ongoing into novel treatments, including new antimicrobials, nebulised therapies and monoclonal antibodies. Future research would benefit from a focussed approach that aims to standardise clinical and research definitions and treats NV-HAP as a separate entity to VAP. Collection of specific data would allow for the development of risk-stratification or severity tools which have been fundamental in improving the management of other pneumonia patients, for example, the use of CURB-65 in CAP. Review of commonplace supportive measures in the NV-HAP population would also be beneficial in view of the mostly frail co-morbid population affected.
Effects of Unstructured Mobility Programs in Older Hospitalized General Medicine Patients: A Systematic Review and Meta-Analysis
2021, Journal of the American Medical Directors Association
Citation Excerpt :
In addition, Cohen and colleagues19 reported a significant reduction in ADL decline 1 month postdischarge in the mobility group; however, there was no difference between groups for IADL at the 1-month follow-up. Nine of the 13 studies assessed the effect of mobility programs compared with usual care on LOS in general medicine units.13–15,20,22,23,25–27 A random effects meta-analysis of 2 RCTs including 526 participants showed no evidence of an overall effect of unstructured mobility interventions on LOS (mean difference –0.36, 95% CI –1.92 to 1.21) and substantial heterogeneity (I2 = 68%) (Figure 3).25,26
Mobility interventions have been shown to mitigate functional decline in various clinical populations; however, the effects of mobility programs in older hospitalized patients are unclear. The objective of this study was to determine the effects of unstructured mobility programs on physical activity, physical function, length of stay (LOS), and quality of life (QOL) in older (≥60 years) general medicine inpatients.
In this systematic review and meta-analysis, we systematically searched MEDLINE, Embase, CINAHL, and AMED databases from inception to March 2020, plus hand screening references of relevant studies.
We included randomized controlled trials (RCTs) and quasi-experimental studies assessing the effects of mobility programs compared to usual care in older adults admitted to general medicine units.
Teams of 2 reviewers independently extracted data, assessed risk of bias, and evaluated quality of evidence. Where study population, intervention, and outcomes were similar, results from RCTs were combined by meta-analysis.
Three RCTs and 10 quasi-experimental studies met eligibility criteria. Interventions mainly included ambulation and staff, patient, or caregiver education. Meta-analyses showed that mobility interventions had a moderate effect on physical activity [step count standardized mean difference 0.60, 95% confidence interval (CI) 0.23-0.97] and a nonsignificant effect on LOS (mean difference –0.36, 95% CI –1.92 to 1.21), both favoring mobility. Narrative synthesis showed consistent evidence for improvement in physical function, potential decrease in LOS, and no increase in adverse events with mobility interventions.
Unstructured mobility interventions in general medicine units may improve older hospitalized patients’ physical activity and physical function; however, the quality of evidence was low. More RCTs are needed to evaluate the effectiveness of mobility interventions, particularly on LOS and QOL.
Reply to «Rational use of antimicrobials in home hospitalization«
2021, Enfermedades Infecciosas y Microbiologia Clinica
Community-Acquired Pneumonia
2021, Encyclopedia of Respiratory Medicine, Second Edition
Community-acquired pneumonia (CAP) remains one of the most frequent causes of death worldwide, and the most common infection requiring hospitalization. Worldwide CAP is the leading infectious disease cause of death and the fourth leading cause of death overall and the leading cause of death in children. While most of the literature on CAP is on patients who become ill enough to require admission to hospital, less severe disease that is treated in the outpatient setting is also exceptionally common.
Interventions for reducing hospital-associated deconditioning: A systematic review and meta-analysis
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No studies reported health-related quality of life as an outcome. Health utilisation costs were assessed by hospital length of stay (Lenze et al., 2012; Mundy et al., 2003; Timmer et al., 2019), hospital re-admission (Hastings et al., 2014; Landefeld et al., 1995; Mundy et al., 2003; Timmer et al., 2019), and nursing home placement (Counsell et al., 2000; Landefeld et al., 1995; Liu et al., 2018). There was moderate-quality evidence (downgraded by risk of bias) of no benefit of enhanced programmes of usual care for hospital length of stay (MD: −0.59; 95 % -1.64 to 0.46; N = 574).
To determine the effectiveness of hospital-based interventions designed to reduce Hospital-Associated Deconditioning (HAD) for people in inpatient hospital settings.
Systematic literature search of published and unpublished databases was conducted from (inception to 01 June 2020). Randomised and non-randomised controlled trials investigating the effectiveness of enhanced inpatient programmes aimed to reduce HAD in adults admitted to a hospital ward were included. Evidence was appraised using the Cochrane Risk of Bias tool and outcomes evaluated against the GRADE criteria. Where appropriate, data were pooled in meta-analyses and presented as risk difference (RD) or standardised mean difference with 95 % confidence intervals (CI).
Seven studies recruiting 12,597 participants (7864 enhanced programmes; 4349 usual care) were included. There was low-quality evidence for reduced risk of decline in physical performance for those in the enhanced programmes compared to usual care (RD: −0.04; 95 % CI: −0.08 to −0.01; N = 2085). There was low- or very-low quality evidence reporting no benefit of enhanced programmes for mobility on discharge, length of hospital stay, hospital readmission, and mortality within the first three-months post-admission (p > 0.05). There was low-quality evidence that nursing home placement and mortality at 12-months was superior through enhanced inpatient programmes compared to usual care.
Enhanced inpatient programmes targeted at HAD may offer benefit over usual care for some outcomes. There remain uncertainty in relation to how applicable the findings are to non-North American countries, which elements of an enhanced programme are most important to reduce HAD, and longer-term sequelae.
Prevention practices for nonventilator hospital-Acquired pneumonia: A survey of the Society for Healthcare Epidemiology of America (SHEA) Research Network (SRN)
2022, Infection Control and Hospital Epidemiology

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This project was funded by the Innovations for Healthcare Program of the Center for Healthcare Quality and Effectiveness, BJC Health System, St. Louis, MO.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (e-mail: [email protected]).

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Chest

Clinical InvestigationsINFECTIONEarly Mobilization of Patients Hospitalized With Community-Acquired Pneumonia

Study objective:

Design:

Setting:

Participants:

Intervention:

Measurements and results:

Conclusions:

Section snippets

Protocol

Patients

Discussion

ACKNOWLEDGMENT

Medicare and Medicaid statistical supplement, 1997 [abstract]

Health Care Finance Rev

A prediction rule to identify low-risk patients with community-acquired pneumonia

N Engl J Med

The clinical benefit of in-hospital observation of “low risk” pneumonia patients after conversion to oral antimicrobial therapy

Chest

Early switch from intravenous to oral cephalosporins in the treatment of hospitalized patients with community-acquired pneumonia

Arch Intern Med

Switch therapy in community-acquired pneumonia

Diag Microbiol Infect Dis

Doxycycline is a cost-effective therapy for hospitalized patients with community-acquired pneumonia

Arch Intern Med

Practice guidelines for the management of community-acquired pneumonia in adults

Clin Infect Dis

Guidelines for the initial management of adults with community-acquired pneumonia: diagnosis, assessment of severity, and initial antimicrobial therapy

Am Rev Respir Dis

Early ambulation after myocardial infarction: the in-patient exercise program

Clin Sports Med

Early inpatient rehabilitation after elective hip and knee arthroplasty

JAMA

Clinical Investigations
INFECTION
Early Mobilization of Patients Hospitalized With Community-Acquired Pneumonia