Regaining pre-fracture basic mobility status after hip fracture and association with post-discharge mortality and readmission-a nationwide register study in Denmark.

BACKGROUND: early mobilization after hip fracture (HF) is an important predictor of outcome, but knowledge of the consequences of not achieving the pre-fracture basic mobility status in acute hospital recovery is sparse. OBJECTIVE: we examined whether the regain of pre-fracture basic mobility status evaluated with the cumulated ambulation score (CAS) at hospital discharge was associated with 30-day post-discharge mortality and readmission. DESIGN: this is a population-based cohort study. MEASURES: using the nationwide Danish Multidisciplinary HF Database from January 2015 through December 2015, 5,147 patients 65 years or older undergoing surgery for a first-time HF were included. The pre-fracture and discharge CAS score (0-6 points with six points indicating an independent basic mobility status) were recorded. CAS was dichotomized as regained or not and entered into adjusted Cox regression overall analysis and stratified by sex, age, body mass index, Charlson comorbidity index, type of fracture, residential status and length of acute hospital stay. Outcome measures were 30-day post-discharge mortality and readmission. RESULTS: overall mortality and readmission were 8.3% (n = 425) and 17.1% (n = 882), respectively. Mortality was 3.5% (n = 71) among patients who regained their pre-fracture CAS score compared with 11.4% (n = 354) among those who did not. Adjusted hazard ratios for 30-day mortality and readmission were 2.76 (95% confidence interval [CI] = 2.01-3.78) and 1.26 (95% CI = 1.07, 1.48), respectively, for patients who did not regain their pre-fracture CAS compared with those who did. CONCLUSIONS: we found that the loss of pre-fracture basic mobility level upon acute hospital discharge was associated with increased 30-day post-discharge mortality and readmission after a first time HF.

Very early versus delayed mobilisation after stroke.

BACKGROUND: Very early mobilisation (VEM) is performed in some stroke units and recommended in some acute stroke clinical guidelines. However, it is unclear whether very early mobilisation independently improves outcome after stroke. OBJECTIVES: To determine whether very early mobilisation (started as soon as possible, and no later than 48 hours after onset of symptoms) in people with acute stroke improves recovery (primarily the proportion of independent survivors) compared with usual care. SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register (last searched 31 July 2017). We also systematically searched 19 electronic databases including; CENTRAL; 2017, Issue 7 in the Cochrane Library (searched July 2017), MEDLINE Ovid (1950 to August 2017), Embase Ovid (1980 to August 2017), CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to August 2017) , PsycINFO Ovid (1806 to August 2017), AMED Ovid (Allied and Complementary Medicine Database), SPORTDiscus EBSCO (1830 to August 2017). We searched relevant ongoing trials and research registers (searched December 2016), the Chinese medical database, Wanfangdata (searched to November 2016), and reference lists, and contacted researchers in the field. SELECTION CRITERIA: Randomised controlled trials (RCTs) of people with acute stroke, comparing an intervention group that started out-of-bed mobilisation within 48 hours of stroke, and aimed to reduce time-to-first mobilisation, with or without an increase in the amount or frequency (or both) of mobilisation activities, with usual care, where time-to-first mobilisation was commenced later. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials, extracted data, assessed risk of bias, and applied the GRADE approach to assess the quality of the evidence. The primary outcome was death or poor outcome (dependency or institutionalisation) at the end of scheduled follow-up. Secondary outcomes included death, dependency, institutionalisation, activities of daily living (ADL), extended ADL, quality of life, walking ability, complications (e.g. deep vein thrombosis), patient mood, and length of hospital stay. We also analysed outcomes at three-month follow-up. MAIN RESULTS: We included nine RCTs with 2958 participants; one trial provided most of the information (2104 participants). The median (range) delay to starting mobilisation after stroke onset was 18.5 (13.1 to 43) hours in the VEM group and 33.3 (22.5 to 71.5) hours in the usual care group. The median difference within trials was 12.7 (4 to 45.6) hours. Other differences in intervention varied between trials; in five trials, the VEM group were also reported to have received more time in therapy, or more mobilisation activity.Primary outcome data were available for 2542 of 2618 (97.1%) participants randomized and followed up for a median of three months. VEM probably led to similar or slightly more deaths and participants who had a poor outcome, compared with delayed mobilisation (51% versus 49%; odds ratio (OR) 1.08, 95% confidence interval (CI) 0.92 to 1.26; P = 0.36; 8 trials; moderate-quality evidence). Death occurred in 7% of participants who received delayed mobilisation, and 8.5% of participants who received VEM (OR 1.27, 95% CI 0.95 to 1.70; P = 0.11; 8 trials, 2570 participants; moderate-quality evidence), and the effects on experiencing any complication were unclear (OR 0.88; 95% CI 0.73 to 1.06; P = 0.18; 7 trials, 2778 participants; low-quality evidence). Analysis using outcomes collected only at three-month follow-up did not alter the conclusions.The mean ADL score (measured at end of follow-up, with the 20-point Barthel Index) was higher in those who received VEM compared with the usual care group (mean difference (MD) 1.94, 95% CI 0.75 to 3.13, P = 0.001; 8 trials, 9 comparisons, 2630/2904 participants (90.6%); low-quality evidence), but there was substantial heterogeneity (93%). Effect sizes were smaller for outcomes collected at three-month follow-up, rather than later.The mean length of stay was shorter in those who received VEM compared with the usual care group (MD -1.44, 95% CI -2.28 to -0.60, P = 0.0008; 8 trials, 2532/2618 participants (96.7%); low-quality evidence). Confidence in the answer was limited by the variable definitions of length of stay. The other secondary outcome analyses (institutionalisation, extended activities of daily living, quality of life, walking ability, patient mood) were limited by lack of data.Sensitivity analyses by trial quality: none of the outcome conclusions were altered if we restricted analyses to trials with the lowest risk of bias (based on method of randomization, allocation concealment, completeness of follow-up, and blinding of final assessment), or information about the amount of mobilisation.Sensitivity analysis by intervention characteristics: analyses restricted to trials where the mean VEM time-to-first mobilisation was less than 24 hours, showed an odds of death of 1.35 (95% CI 0.99 to 1.83; P = 0.06; I² = 25%; 5 trials). Analyses restricted to the trials that clearly reported a more prolonged out-of-bed activity showed a similar primary outcome (OR 1.14; 0.96 to 1.35; P = 0.13; I² = 28%; 5 trials), and odds of death (OR 1.27; 0.93 to 1.73; P = 0.13; I² = 0%; 4 trials) to the main analysis.Exploratory network meta-analysis (NMA): we were unable to analyze by the amount of therapy, but low-quality evidence indicated that time-to-first mobilisation at around 24 hours was associated with the lowest odds of death or poor outcome, compared with earlier or later mobilisation. AUTHORS' CONCLUSIONS: VEM, which usually involved first mobilisation within 24 hours of stroke onset, did not increase the number of people who survived or made a good recovery after their stroke. VEM may have reduced the length of stay in hospital by about one day, but this was based on low-quality evidence. Based on the potential hazards reported in the single largest RCT, the sensitivity analysis of trials commencing mobilisation within 24 hours, and the NMA, there was concern that VEM commencing within 24 hours may carry an increased risk, at least in some people with stroke. Given the uncertainty around these effect estimates, more detailed research is still required.

Early Ambulation Among Hospitalized Heart Failure Patients Is Associated With Reduced Length of Stay and 30-Day Readmissions.

BACKGROUND: Early ambulation (EA) is associated with improved outcomes for mechanically ventilated and stroke patients. Whether the same association exists for patients hospitalized with acute heart failure is unknown. We sought to determine whether EA among patients hospitalized with heart failure is associated with length of stay, discharge disposition, 30-day post discharge readmissions, and mortality. METHODS AND RESULTS: The study population included 369 hospitals and 285 653 patients with heart failure enrolled in the Get With The Guidelines-Heart Failure registry. We used multivariate logistic regression with generalized estimating equations at the hospital level to identify predictors of EA and determine the association between EA and outcomes. Sixty-five percent of patients ambulated by day 2 of the hospital admission. Patient-level predictors of EA included younger age, male sex, and hospitalization outside of the Northeast (P<0.01 for all). Hospital size and academic status were not predictive. Hospital-level analysis revealed that those hospitals with EA rates in the top 25% were less likely to have a long length of stay (defined as >4 days) compared with those in the bottom 25% (odds ratio, 0.83; confidence interval, 0.73-0.94; P=0.004). Among a subgroup of fee-for-service Medicare beneficiaries, we found that hospitals in the highest quartile of rates of EA demonstrated a statistically significant 24% lower 30-day readmission rates (P<0.0001). Both end points demonstrated a dose-response association and statistically significant P for trend test. CONCLUSIONS: Multivariable-adjusted hospital-level analysis suggests an association between EA and both shorter length of stay and lower 30-day readmissions. Further prospective studies are needed to validate these findings.

Effects of Early Mobilization after Acute Stroke: A Meta-Analysis of Randomized Control Trials.

BACKGROUND: Early mobilization is inconsistently associated with the recovery of stroke. We aim to examine the effect of early mobilization on patients with acute stroke. METHODS: PubMed, EMBASE, and the Cochrane library were searched up to April 2017. Randomized controlled trials that reported risk estimates or mean with standard deviation were included. Primary outcomes were defined as modified Rankin scale score 0-2 and mortality, and secondary outcomes were Barthel Index, length of stay, and incidence of complications. Summary relative risk, standardized mean difference (SMD), and weighted mean difference (WMD) were calculated as needed. Sensitivity analyses were also conducted to test stability of results. RESULTS: Six studies (8 publications) were included to analyze the effects of early mobilization after stroke. No differences between groups were observed for modified Rankin scale 0-2 (relative risk [RR]: .80; 95% confidence interval [CI]: .58-1.02; I2=45%) and the risk of death (RR: 1.21, 95% CI: .76-1.65; I2=0%). Compared with conventional practice, early mobilization was superior in Barthel Index (SMD: .66; 95% CI: .00-1.31; I2=85.9%), and shorter hospital stay for stroke patients (WMD: -1.97; 95% CI: -2.63 to -1.32; I2=15.3%). We found no significant difference between groups on the incidence of complications. CONCLUSIONS: Current evidence revealed that no statistical significant difference between early mobilization and non-early mobilization was observed on modified Rankin scale score 0-2 and mortality. Interestingly, early mobilization is associated with an increased Barthel Index and shorter hospital stay for patients. Further research is necessary to verify the effect of early mobilization on patients with acute stroke.

Early mobilization and recovery in mechanically ventilated patients in the ICU: a bi-national, multi-centre, prospective cohort study.

INTRODUCTION: The aim of this study was to investigate current mobilization practice, strength at ICU discharge and functional recovery at 6 months among mechanically ventilated ICU patients. METHOD: This was a prospective, multi-centre, cohort study conducted in twelve ICUs in Australia and New Zealand. Patients were previously functionally independent and expected to be ventilated for >48 hours. We measured mobilization during invasive ventilation, sedation depth using the Richmond Agitation and Sedation Scale (RASS), co-interventions, duration of mechanical ventilation, ICU-acquired weakness (ICUAW) at ICU discharge, mortality at day 90, and 6-month functional recovery including return to work. RESULTS: We studied 192 patients (mean age 58.1 ± 15.8 years; mean Acute Physiology and Chronic Health Evaluation (APACHE) (IQR) II score, 18.0 (14 to 24)). Mortality at day 90 was 26.6% (51/192). Over 1,351 study days, we collected information during 1,288 planned early mobilization episodes in patients on mechanical ventilation for the first 14 days or until extubation (whichever occurred first). We recorded the highest level of early mobilization. Despite the presence of dedicated physical therapy staff, no mobilization occurred in 1,079 (84%) of these episodes. Where mobilization occurred, the maximum levels of mobilization were exercises in bed (N = 94, 7%), standing at the bed side (N = 11, 0.9%) or walking (N = 26, 2%). On day three, all patients who were mobilized were mechanically ventilated via an endotracheal tube (N = 10), whereas by day five 50% of the patients mobilized were mechanically ventilated via a tracheostomy tube (N = 18). CONCLUSIONS: Early mobilization of patients receiving mechanical ventilation was uncommon. More than 50% of patients discharged from the ICU had developed ICU-acquired weakness, which was associated with death between ICU discharge and day-90. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov NCT01674608. Registered 14 August 2012.

Early versus delayed mobilisation for aneurysmal subarachnoid haemorrhage.

BACKGROUND: Rebleeding is an important cause of death and disability in patients with aneurysmal subarachnoid haemorrhage (SAH). In order to prevent rebleeding, the preferred strategy is aneurysm ablation (removal) as early as possible. However, in clinical practice some patients are not suitable for surgical treatment, or prefer conservative treatments. In some countries, therefore, total bedrest for four to six weeks has been considered one of the basic interventions to avoid rebleeding. However, the influence of bedrest on outcome in patients with SAH is not well known. OBJECTIVES: To establish whether early mobilisation (less than four weeks after symptom onset) compared with delayed mobilisation (defined as patients staying in bed for at least four weeks after symptom onset) in patients with aneurysmal subarachnoid haemorrhage (SAH), who have not had or could not have any surgical treatment for the aneurysm, will increase the proportion of deaths from rebleeding. SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register (May 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 6), the Chinese Stroke Trials Register (May 2012), MEDLINE (1950 to June 2012), EMBASE (1980 to June 2012), Web of Science Conference Proceedings (1990 to May 2012), CINAHL (1982 to June 2012), AMED (1985 to June 2012), PEDro (May 2012), REHABDATA (May 2012) and CIRRIE Database of International Rehabilitation Research (May 2012). In addition, we searched five Chinese databases, ongoing trials registers and relevant reference lists. SELECTION CRITERIA: We planned to include randomised controlled trials (RCTs) comparing early mobilisation (within four weeks after symptom onset) with delayed mobilisation (after four weeks). DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials for inclusion and exclusion. We resolved disagreements by discussion. MAIN RESULTS: In the absence of any suitable RCTs addressing this topic, we were unable to perform a meta-analysis. Data from recent observational studies suggested the period of greatest risk for rebleeding occurs more frequently in the early period, especially within 24 hours of the initial SAH. The impact of bedrest on aneurysm care should be clarified. AUTHORS' CONCLUSIONS: There are no RCTs or controlled trials that provide evidence for, or against, staying in bed for at least four weeks after symptom onset in patients with aneurysmal SAH, who have not had, or could not have, surgical treatment for the aneurysm. Treatment strategies to reduce the risk of rebleeding in SAH patients before aneurysm ablation, or in those not suitable for surgical treatment, or who prefer conservative treatments, deserve attention.

Early mobilization of patients hospitalized with community-acquired pneumonia.

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.