Admission is not Always Necessary for Patients with Community-Acquired Pneumonia in Risk Classes IV and V Diagnosed in the Emergency Room

Tj Marrie,Jq Huang

doi:10.1155/2007/451417

Abstract

To determine the factors that allow patients with community-acquired pneumonia who are at high risk of mortality (risk classes IV and V) to be treated at home. A prospective, observational study. Six hospitals and one free-standing emergency room in Edmonton, Alberta. The present study included 2354 patients in risk classes IV and V who had a diagnosis of pneumonia made by an emergency room physician or an internist. Symptoms, signs and laboratory findings, as well as outcome measures of length of stay and mortality. Of the total study group, 319 of the patients (13.5%) were treated on an ambulatory basis. Factors predictive of admission were definite or possible pneumonia on chest radiograph as read by a radiologist, functional impairment, altered mental status, substance abuse, psychiatric disorder, abnormal white blood cell count, abnormal lymphocyte count, oxygen saturation less than 90% and antibiotic administration in the week before admission. If chest pain was present, admission was less likely. Only two of the 319 patients required subsequent admission (both had positive blood cultures) and only two died. A substantial number of patients in risk classes IV and V can be safely treated at home. Factors that help clinicians to select this subset of patients are discussed.

Highlights

In a prospective study of Community-acquired pneumonia (CAP) [4], we noted that 316 of 2251 patients (14%) in classes IV and V were managed on an ambulatory basis
It is noteworthy that the patients’ residence before admission seemed to influence the admission decision, in that 82.5% of those who were living at home were admitted, while 100% of those who were living in a chronic care facility were admitted
All eight homeless persons and seven persons residing in jail were admitted. Those who were discharged from the emergency department were less likely to have definite pneumonia on chest radiograph (37% versus 51.4% for the admitted group)

Summary

OBJECTIVE

To determine the factors that allow patients with community-acquired pneumonia who are at high risk of mortality (risk classes IV and V) to be treated at home. PARTICIPANTS: The present study included 2354 patients in risk classes IV and V who had a diagnosis of pneumonia made by an emergency room physician or an internist. It should be noted that age is a major factor in this scoring system, because male patients receive one point per year of age, while female patients have 10 points subtracted from the total age points It is usually elderly patients who are in risk classes IV and V. In a prospective study of CAP [4], we noted that 316 of 2251 patients (14%) in classes IV and V were managed on an ambulatory basis. The present paper compares the two groups of patients and provides data that should allow physicians to manage some of their class IV and V patients in an ambulatory setting. Predisposing factors, clinical, laboratory and radiological findings, and mortality in ambulatory and admitted patients were compared using a univariate model. The HosmerLemeshow lack-of-fit test was used to evaluate the adequacy of the logistic regression models

RESULTS

DISCUSSION

CONCLUSIONS