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Standardized Rehabilitation and Hospital Length of Stay Among Patients With Acute Respiratory Failure: A Randomized Clinical Trial.

ABSTRACT: IMPORTANCE:Physical rehabilitation in the intensive care unit (ICU) may improve the outcomes of patients with acute respiratory failure. OBJECTIVE:To compare standardized rehabilitation therapy (SRT) to usual ICU care in acute respiratory failure. DESIGN, SETTING, AND PARTICIPANTS:Single-center, randomized clinical trial at Wake Forest Baptist Medical Center, North Carolina. Adult patients (mean age, 58 years; women, 55%) admitted to the ICU with acute respiratory failure requiring mechanical ventilation were randomized to SRT (n=150) or usual care (n=150) from October 2009 through May 2014 with 6-month follow-up. INTERVENTIONS:Patients in the SRT group received daily therapy until hospital discharge, consisting of passive range of motion, physical therapy, and progressive resistance exercise. The usual care group received weekday physical therapy when ordered by the clinical team. For the SRT group, the median (interquartile range [IQR]) days of delivery of therapy were 8.0 (5.0-14.0) for passive range of motion, 5.0 (3.0-8.0) for physical therapy, and 3.0 (1.0-5.0) for progressive resistance exercise. The median days of delivery of physical therapy for the usual care group was 1.0 (IQR, 0.0-8.0). MAIN OUTCOMES AND MEASURES:Both groups underwent assessor-blinded testing at ICU and hospital discharge and at 2, 4, and 6 months. The primary outcome was hospital length of stay (LOS). Secondary outcomes were ventilator days, ICU days, Short Physical Performance Battery (SPPB) score, 36-item Short-Form Health Surveys (SF-36) for physical and mental health and physical function scale score, Functional Performance Inventory (FPI) score, Mini-Mental State Examination (MMSE) score, and handgrip and handheld dynamometer strength. RESULTS:Among 300 randomized patients, the median hospital LOS was 10 days (IQR, 6 to 17) for the SRT group and 10 days (IQR, 7 to 16) for the usual care group (median difference, 0 [95% CI, -1.5 to 3], P?=?.41). There was no difference in duration of ventilation or ICU care. There was no effect at 6 months for handgrip (difference, 2.0 kg [95% CI, -1.3 to 5.4], P?=?.23) and handheld dynamometer strength (difference, 0.4 lb [95% CI, -2.9 to 3.7], P?=?.82), SF-36 physical health score (difference, 3.4 [95% CI, -0.02 to 7.0], P?=?.05), SF-36 mental health score (difference, 2.4 [95% CI, -1.2 to 6.0], P?=?.19), or MMSE score (difference, 0.6 [95% CI, -0.2 to 1.4], P?=?.17). There were higher scores at 6 months in the SRT group for the SPPB score (difference, 1.1 [95% CI, 0.04 to 2.1, P?=?.04), SF-36 physical function scale score (difference, 12.2 [95% CI, 3.8 to 20.7], P?=?.001), and the FPI score (difference, 0.2 [95% CI, 0.04 to 0.4], P?=?.02). CONCLUSIONS AND RELEVANCE:Among patients hospitalized with acute respiratory failure, SRT compared with usual care did not decrease hospital LOS. TRIAL REGISTRATION:clinicaltrials.gov Identifier: NCT00976833.

SUBMITTER: Morris PE

PROVIDER: S-EPMC6657499 | biostudies-literature | 2016 Jun

REPOSITORIES: biostudies-literature

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Standardized Rehabilitation and Hospital Length of Stay Among Patients With Acute Respiratory Failure: A Randomized Clinical Trial.

Morris Peter E PE Berry Michael J MJ Files D Clark DC Thompson J Clifton JC Hauser Jordan J Flores Lori L Dhar Sanjay S Chmelo Elizabeth E Lovato James J Case L Douglas LD Bakhru Rita N RN Sarwal Aarti A Parry Selina M SM Campbell Pamela P Mote Arthur A Winkelman Chris C Hite Robert D RD Nicklas Barbara B Chatterjee Arjun A Young Michael P MP

JAMA 20160601 24

<h4>Importance</h4>Physical rehabilitation in the intensive care unit (ICU) may improve the outcomes of patients with acute respiratory failure.<h4>Objective</h4>To compare standardized rehabilitation therapy (SRT) to usual ICU care in acute respiratory failure.<h4>Design, setting, and participants</h4>Single-center, randomized clinical trial at Wake Forest Baptist Medical Center, North Carolina. Adult patients (mean age, 58 years; women, 55%) admitted to the ICU with acute respiratory failure r ...[more]

PMID: 27367766

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Project description:ImportanceAlthough racial and ethnic minority patients with sepsis and acute respiratory failure (ARF) experience worse outcomes, how patient presentation characteristics, processes of care, and hospital resource delivery are associated with outcomes is not well understood.ObjectiveTo measure disparities in hospital length of stay (LOS) among patients at high risk of adverse outcomes who present with sepsis and/or ARF and do not immediately require life support and to quantify associations with patient- and hospital-level factors.Design, setting, and participantsThis matched retrospective cohort study used electronic health record data from 27 acute care teaching and community hospitals across the Philadelphia metropolitan and northern California areas between January 1, 2013, and December 31, 2018. Matching analyses were performed between June 1 and July 31, 2022. The study included 102 362 adult patients who met clinical criteria for sepsis (n = 84 685) or ARF (n = 42 008) with a high risk of death at the time of presentation to the emergency department but without an immediate requirement for invasive life support.ExposuresRacial or ethnic minority self-identification.Main outcomes and measuresHospital LOS, defined as the time from hospital admission to the time of discharge or inpatient death. Matches were stratified by racial and ethnic minority patient identity, comparing Asian and Pacific Islander patients, Black patients, Hispanic patients, and multiracial patients with White patients in stratified analyses.ResultsAmong 102 362 patients, the median (IQR) age was 76 (65-85) years; 51.5% were male. A total of 10.2% of patients self-identified as Asian American or Pacific Islander, 13.7% as Black, 9.7% as Hispanic, 60.7% as White, and 5.7% as multiracial. After matching racial and ethnic minority patients to White patients on clinical presentation characteristics, hospital capacity strain, initial intensive care unit admission, and the occurrence of inpatient death, Black patients experienced longer LOS relative to White patients in fully adjusted matches (sepsis: 1.26 [95% CI, 0.68-1.84] days; ARF: 0.97 [95% CI, 0.05-1.89] days). Length of stay was shorter among Asian American and Pacific Islander patients with ARF (-0.61 [95% CI, -0.88 to -0.34] days) and Hispanic patients with sepsis (-0.22 [95% CI, -0.39 to -0.05] days) or ARF (-0.47 [-0.73 to -0.20] days).Conclusions and relevanceIn this cohort study, Black patients with severe illness who presented with sepsis and/or ARF experienced longer LOS than White patients. Hispanic patients with sepsis and Asian American and Pacific Islander and Hispanic patients with ARF both experienced shorter LOS. Because matched differences were independent of commonly implicated clinical presentation-related factors associated with disparities, identification of additional mechanisms that underlie these disparities is warranted.

Project description:ObjectiveWe examined the consequences of perioperative respiratory event (PRE) in terms of hospitalization and hospital cost in children who underwent ambulatory surgery.MethodsThis subgroup analysis of a prospective cohort study (ClinicalTrials.gov: NCT02036021) was conducted in children aged between 1 month and 14 years who underwent ambulatory surgery between November 2012 and December 2013. Exposure was the presence of PRE either intraoperatively or in the postanesthetic care unit or both. The primary outcome was length of stay after surgery. The secondary outcome was excess hospital cost excluding surgical cost. Financial information was also compared between PRE and non-PRE. Directed acyclic graphs were used to select the covariates to be included in the multivariate regression models. The predictors of length of stay and excess hospital cost between PRE and non-PRE children are presented as adjusted odds ratio (OR) and cost ratio (CR), respectively with 95% confidence interval (CI).ResultsSixty-three PRE and 249 non-PRE patients were recruited. In the univariate analysis, PRE was associated with length of stay (p = 0.004), postoperative oxygen requirement (p <0.001), and increased hospital charge (p = 0.006). After adjustments for age, history of snoring, American Society of Anesthesiologists physical status, type of surgery and type of payment, preoperative planned admission had an effect modification with PRE (p <0.001). The occurrence of PRE in the preoperative unplanned admission was associated with 24-fold increased odds of prolonged hospital stay (p <0.001). PRE was associated with higher excess hospital cost (CR = 1.35, p = 0.001). The mean differences in contribution margin for total procedure (per patient) (PRE vs non-PRE) differed significantly (mean = 1,523; 95% CI: 387, 2,658 baht).ConclusionPRE with unplanned admission was significantly associated with prolonged length of stay whereas PRE regardless of unplanned admission increased hospital cost by 35% in pediatric ambulatory surgery.Trial registrationClinicalTrials.gov registration number NCT02036021.

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Standardized Rehabilitation and Hospital Length of Stay Among Patients With Acute Respiratory Failure: A Randomized Clinical Trial.

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Standardized Rehabilitation and Hospital Length of Stay Among Patients With Acute Respiratory Failure: A Randomized Clinical Trial.

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