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Abstract & Commentary
Synopsis: 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.
Source: Mundy LM, et al. Chest. 2003;124(3):883-889.
This prospective, randomized trial assessed the effect of early ambulation on length of stay and morbidity in patients admitted for community-acquired pneumonia (CAP). In this trial, 711 consecutive patients admitted with CAP were enrolled; 458 met the inclusion criteria of no prior hospitalization within 2 weeks, no ICU admission criteria and no large-volume aspiration pneumonia. Specific medical units were randomized to begin either usual care or an early mobilization (EM) protocol. The EM protocol consisted of the patient being out of bed in an upright posture for at least 20 minutes on the first day, with subsequent increases in upright posture and ambulation on subsequent days. The treatment and control groups were similar in all collected demographics, including PORT and SF-12 scores.1,2
Patients assigned to usual care had a mean length of stay of 6.9 days; those assigned to the early mobilization protocol had a 5.9-day mean length of stay (95% CI, 0.2-2.2; P = 0.06). As would be expected, patients with the lowest PORT risk scores (I and II) had the greatest likelihood of achieving early mobilization, though the treatment effect was marginal in these groups. The greatest effect was seen in the PORT III class, with a 2.6-day reduction in length of stay (95% CI, 0.2-5.0; P =0.05). The estimated cost per admission was $10,159 for the intervention; $12,868 for the control. There was no statistical difference in mortality between the 2 groups.
Comment by Jeff Wiese, MD
The results of this trial suggest that early mobilization beginning on the first day of hospitalization can reduce costs and length of stay in patients with CAP. One potential explanation is that early mobilization results in better aeration of lung tissue, thereby facilitating mobilization of pulmonary secretions and quicker resolution of the pneumonia. Another possible explanation is that enhanced nursing care resulted in greater compliance to the medical regimen and more vigilant observation for and response to complications. Physicians were blinded to the treatment and control assignments, making a Hawthorne effect unlikely.
The results of this study should be interpreted with caution, however. Aside from the PORT III class of patients, none of the end points were statistically significant. The confidence intervals for all end points were wide, suggesting that the study was underpowered with its subject enrollment. Subsequent studies will be required to confirm these results, although the effect size of the intervention is large, suggesting that larger trials will likely confirm the same.
The most interesting feature of the study is the effect in patients with PORT III classification, as these are typically the most ill of patients allowed to remain on the medical wards (ie, non-ICU care). The robust and statistically significant reduction in length of stay and cost suggest that even patients’ physicians do not routinely deem capable of early mobilization benefit from such an intervention. In designing hospital care protocols, this subgroup may be a target of allocating additional physical therapy and nursing resources to reduce length of stay and hospital cost.
This trial was not large enough to assess for complications of pneumonia therapy, including DVT and compression ulcers. It is likely, however, that with a greater sample size, early mobilization would also show benefit in these outcomes.3
Dr. Wiese, Chief of Medicine, Charity, and University Hospitals, Associate Chairman of Medicine, Tulane Health Sciences Center, is Associate Editor of Internal Medicine Alert.
1. Fine MJ, et al. N Engl J Med. 1997;336:243-250.
2. Ware JE, et al. Med Care. 1996;32:220-233.
3. Munin MC, et al. JAMA. 1998;279:847-852.