This Article  • Full text  • PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Citing articles on ISI (133)  • Contact me when this article is cited  Related Content  • Related letters  • Similar articles in JAMA  Topic Collections  • Bacterial Infections  • Infectious Diseases, Other  • Pneumonia  • Alert me on articles by topic

Implications for Practice Guidelines

Ethan A. Halm, MD, MPH; Michael J. Fine, MD, MSc; Thomas J. Marrie, MD; Christopher M. Coley, MD; Wishwa N. Kapoor, MD, MPH; D. Scott Obrosky, MS; Daniel E. Singer, MD

JAMA. 1998;279:1452-1457.

Context.— Many groups have developed guidelines to shorten hospital length of stay in pneumonia in order to decrease costs, but the length of time until a patient hospitalized with pneumonia becomes clinically stable has not been established.

Objective.— To describe the time to resolution of abnormalities in vital signs, ability to eat, and mental status in patients with community-acquired pneumonia and assess clinical outcomes after achieving stability.

Design.— Prospective, multicenter, observational cohort study.

Setting.— Three university and 1 community teaching hospital in Boston, Mass, Pittsburgh, Pa, and Halifax, Nova Scotia.

Patients.— Six hundred eighty-six adults hospitalized with community-acquired pneumonia.

Main Outcome Measures.— Time to resolution of vital signs, ability to eat, mental status, hospital length of stay, and admission to an intensive care, coronary care, or telemetry unit.

Results.— The median time to stability was 2 days for heart rate (100 beats/min) and systolic blood pressure (90 mm Hg), and 3 days for respiratory rate (24 breaths/min), oxygen saturation (90%), and temperature (37.2°C [99°F]). The median time to overall clinical stability was 3 days for the most lenient definition of stability and 7 days for the most conservative definition. Patients with more severe cases of pneumonia at presentation took longer to reach stability. Once stability was achieved, clinical deterioration requiring intensive care, coronary care, or telemetry monitoring occurred in 1% of cases or fewer. Between 65% to 86% of patients stayed in the hospital more than 1 day after reaching stability, and fewer than 29% to 46% were converted to oral antibiotics within 1 day of stability, depending on the definition of stability.

Conclusions.— Our estimates of time to stability in pneumonia and explicit criteria for defining stability can provide an evidence-based estimate of optimal length of stay, and outline a clinically sensible approach to improving the efficiency of inpatient management.

From the Departments of Health Policy and Medicine, Mount Sinai School of Medicine, New York, NY (Dr Halm); Division of General Internal Medicine, Department of Medicine, and Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pa (Drs Fine and Kapoor and Mr Obrosky); Department of Medicine and Microbiology, Victoria General Hospital and Dalhousie University, Halifax, Nova Scotia (Dr Marrie); General Medicine Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (Drs Coley and Singer).

RELATED LETTERS

Time to Clinical Stability for Patients With Community-Acquired Pneumonia
Robert E. Siegel, Ethan A. Halm, Michael J. Fine, and Daniel E. Singer
JAMA. 1999;281(3):231-232.
EXTRACT | FULL TEXT  

Hospitalizations for Dog Bite Injuries
Kyran P. Quinlan and Jeffrey J. Sacks
JAMA. 1999;281(3):232-233.
EXTRACT | FULL TEXT  

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Usefulness of consecutive C-reactive protein measurements in follow-up of severe community-acquired pneumonia
Bruns et al.
Eur Respir J 2008;32:726-732.
ABSTRACT | FULL TEXT  

Early mortality in patients with community-acquired pneumonia: causes and risk factors
Garcia-Vidal et al.
Eur Respir J 2008;32:733-739.
ABSTRACT | FULL TEXT  

Pneumonia: Criteria for Patient Instability on Hospital Discharge
Capelastegui et al.
Chest 2008;134:595-600.
ABSTRACT | FULL TEXT  

Markers of treatment failure in hospitalised community acquired pneumonia
Menendez et al.
Thorax 2008;63:447-452.
ABSTRACT | FULL TEXT  

Length of Stay and Mortality in Pulmonary Embolism: High Time for Evidence-Based Discharge Criteria
Brotman and Lindenauer
Arch Intern Med 2008;168:683-684.
FULL TEXT  

Serum zinc and pneumonia in nursing home elderly
Meydani et al.
Am. J. Clin. Nutr. 2007;86:1167-1173.
ABSTRACT | FULL TEXT  

Treatment Failure in Community-Acquired Pneumonia
Menendez and Torres
Chest 2007;132:1348-1355.
ABSTRACT | FULL TEXT  

Understanding the Inflammatory Cytokine Response in Pneumonia and Sepsis: Results of the Genetic and Inflammatory Markers of Sepsis (GenIMS) Study
Kellum et al.
Arch Intern Med 2007;167:1655-1663.
ABSTRACT | FULL TEXT  

The Impact of Standardized Order Sets and Intensive Clinical Case Management on Outcomes in Community-Acquired Pneumonia
Fishbane et al.
Arch Intern Med 2007;167:1664-1669.
ABSTRACT | FULL TEXT  

Prospective comparison of three predictive rules for assessing severity of community-acquired pneumonia in Hong Kong
Yan Man et al.
Thorax 2007;62:348-353.
ABSTRACT | FULL TEXT  

Severe community acquired pneumonia
Mills and Laing
BMJ 2006;333:1181-1182.
FULL TEXT  

Effect of a clinical pathway to reduce hospitalizations in nursing home residents with pneumonia: a randomized controlled trial.
Loeb et al.
JAMA 2006;295:2503-2510.
ABSTRACT | FULL TEXT  

Severe sepsis in community-acquired pneumonia: when does it happen, and do systemic inflammatory response syndrome criteria help predict course?
Dremsizov et al.
Chest 2006;129:968-978.
ABSTRACT | FULL TEXT  

Validation of a predictive rule for the management of community-acquired pneumonia
Capelastegui et al.
Eur Respir J 2006;27:151-157.
ABSTRACT | FULL TEXT  

Guidelines for the management of adult lower respiratory tract infections
Woodhead et al.
Eur Respir J 2005;26:1138-1180.
ABSTRACT | FULL TEXT  

Monotherapy in Severe Community-Acquired Pneumonia: Is It Worthy?
Torres
Chest 2005;128:10-13.
FULL TEXT  

C-reactive protein as a marker of ventilator-associated pneumonia resolution: a pilot study
Povoa et al.
Eur Respir J 2005;25:804-812.
ABSTRACT | FULL TEXT  

Factors Influencing In-hospital Mortality in Community-Acquired Pneumonia: A Prospective Study of Patients Not Initially Admitted to the ICU
Marrie and Wu
Chest 2005;127:1260-1270.
ABSTRACT | FULL TEXT  

Outpatient Care Compared with Hospitalization for Community-Acquired Pneumonia: A Randomized Trial in Low-Risk Patients
Carratala et al.
ANN INTERN MED 2005;142:165-172.
ABSTRACT | FULL TEXT  

Identifying failure of empirical treatment for pneumonia: vigilance and common sense
Lim
Thorax 2004;59:918-919.
FULL TEXT  

Limited Impact of a Multicenter Intervention To Improve the Quality and Efficiency of Pneumonia Care
Halm et al.
Chest 2004;126:100-107.
ABSTRACT | FULL TEXT  

Causes and Factors Associated With Early Failure in Hospitalized Patients With Community-Acquired Pneumonia
Roson et al.
Arch Intern Med 2004;164:502-508.
ABSTRACT | FULL TEXT  

What Is the Prognosis for Using the Pneumonia Severity Index To Make Site-of-Care Decisions In Community-Acquired Pneumonia?
Niederman
Chest 2003;124:2051-2053.
FULL TEXT  

Conversion From Intravenous to Oral Medications: Assessment of a Computerized Intervention for Hospitalized Patients
Fischer et al.
Arch Intern Med 2003;163:2585-2589.
ABSTRACT | FULL TEXT  

Early Administration of Antibiotics Does Not Shorten Time to Clinical Stability in Patients With Moderate-to-Severe Community-Acquired Pneumonia
Silber et al.
Chest 2003;124:1798-1804.
ABSTRACT | FULL TEXT  

Duration of length of stay in pneumonia: influence of clinical factors and hospital type
Menendez et al.
Eur Respir J 2003;22:643-648.
ABSTRACT | FULL TEXT  

Shoot, Ready, Aim: Pneumonia Care Quality and Costs in a Community Hospital
Milo et al.
American Journal of Medical Quality 2003;18:214-219.
ABSTRACT  

" 'Tis a gift to be simple... "
Wunderink
Chest 2003;124:777-778.
FULL TEXT  

Early Mobilization of Patients Hospitalized With Community-Acquired Pneumonia
Mundy et al.
Chest 2003;124:883-889.
ABSTRACT | FULL TEXT  

Azithromycin Monotherapy for Patients Hospitalized With Community-Acquired Pneumonia: A 31/2-Year Experience From a Veterans Affairs Hospital
Feldman et al.
Arch Intern Med 2003;163:1718-1726.
ABSTRACT | FULL TEXT  

Management of Community-Acquired Pneumonia
Halm and Teirstein
NEJM 2002;347:2039-2045.
FULL TEXT  

Severe Community-acquired Pneumonia: Use of Intensive Care Services and Evaluation of American and British Thoracic Society Diagnostic Criteria
Angus et al.
Am. J. Respir. Crit. Care Med. 2002;166:717-723.
ABSTRACT | FULL TEXT  

Instability on Hospital Discharge and the Risk of Adverse Outcomes in Patients With Pneumonia
Halm et al.
Arch Intern Med 2002;162:1278-1284.
ABSTRACT | FULL TEXT  

Quality Indicators for the Management of Pneumonia in Vulnerable Elders
Rhew
ANN INTERN MED 2001;135:736-743.
FULL TEXT  

Processes of Care, Illness Severity, and Outcomes in the Management of Community-Acquired Pneumonia at Academic Hospitals
Dedier et al.
Arch Intern Med 2001;161:2099-2104.
ABSTRACT | FULL TEXT  

Early Discharge of Infected Patients Through Appropriate Antibiotic Use: A Response
Ravakhah et al.
Arch Intern Med 2001;161:2047-2048.
FULL TEXT  

Initial risk class and length of hospital stay in community-acquired pneumonia
Menendez et al.
Eur Respir J 2001;18:151-156.
ABSTRACT | FULL TEXT  

Guidelines for the Management of Adults with Community-acquired Pneumonia . Diagnosis, Assessment of Severity, Antimicrobial Therapy, and Prevention
Niederman et al.
Am. J. Respir. Crit. Care Med. 2001;163:1730-1754.
FULL TEXT  

Functional and metabolic early changes in calf muscle occurring during nutritional repletion in malnourished elderly patients
Bourdel-Marchasson et al.
Am. J. Clin. Nutr. 2001;73:832-838.
ABSTRACT | FULL TEXT  

Early Discharge of Infected Patients Through Appropriate Antibiotic Use
Eron and Passos
Arch Intern Med 2001;161:61-65.
ABSTRACT | FULL TEXT  

Community-Acquired Pneumonia in Elderly Patients and Length of Hospitalization
Masotti et al.
Arch Intern Med 2000;160:2678-2679.
FULL TEXT  

Are Elderly Patients with Obstructive Airway Disease Being Prematurely Discharged?
SIN and TU
Am. J. Respir. Crit. Care Med. 2000;161:1513-1517.
ABSTRACT | FULL TEXT  

Pediatric Milliman and Robertson Length-of-Stay Criteria: Are They Realistic?
Sills et al.
Pediatrics 2000;105:733-737.
ABSTRACT | FULL TEXT  

Early Switch From Intravenous to Oral Antibiotics and Early Hospital Discharge: A Prospective Observational Study of 200 Consecutive Patients With Community-Acquired Pneumonia
Ramirez et al.
Arch Intern Med 1999;159:2449-2454.
ABSTRACT | FULL TEXT  

Time to Clinical Stability for Patients With Community-Acquired Pneumonia
Siegel et al.
JAMA 1999;281:231-232.
FULL TEXT  

When Do Patients Hospitalized with Pneumonia Become Clinically Stable?
JWatch Infect. Diseases 1998;1998:6-6.
FULL TEXT  

Delayed Discharge for Community-Acquired Pneumonia
JWatch General 1998;1998:3-3.
FULL TEXT