Abstract
IntroductionTo identify risk factors for early (< three days) intensive care unit (ICU) admission of patients hospitalised with community-acquired pneumonia (CAP) and not requiring immediate ICU admission, and to stratify the risk of ICU admission on days 1 to 3.MethodsUsing the original data from four North American and European prospective multicentre cohort studies of patients with CAP, we derived and validated a prediction rule for ICU admission on days 1 to 3 of emergency department (ED) presentation, for patients presenting with no obvious reason for immediate ICU admission (not requiring immediate respiratory or circulatory support).ResultsA total of 6560 patients were included (4593 and 1967 in the derivation and validation cohort, respectively), 303 (4.6%) of whom were admitted to an ICU on days 1 to 3. The Risk of Early Admission to ICU index (REA-ICU index) comprised 11 criteria independently associated with ICU admission: male gender, age younger than 80 years, comorbid conditions, respiratory rate of 30 breaths/minute or higher, heart rate of 125 beats/minute or higher, multilobar infiltrate or pleural effusion, white blood cell count less than 3 or 20 G/L or above, hypoxaemia (oxygen saturation < 90% or arterial partial pressure of oxygen (PaO2) < 60 mmHg), blood urea nitrogen of 11 mmol/L or higher, pH less than 7.35 and sodium less than 130 mEq/L. The REA-ICU index stratified patients into four risk classes with a risk of ICU admission on days 1 to 3 ranging from 0.7 to 31%. The area under the curve was 0.81 (95% confidence interval (CI) = 0.78 to 0.83) in the overall population.ConclusionsThe REA-ICU index accurately stratifies the risk of ICU admission on days 1 to 3 for patients presenting to the ED with CAP and no obvious indication for immediate ICU admission and therefore may assist orientation decisions.
Highlights
To identify risk factors for early (< three days) intensive care unit (ICU) admission of patients hospitalised with community-acquired pneumonia (CAP) and not requiring immediate ICU admission, and to stratify the risk of ICU admission on days 1 to 3
10% of patients hospitalised for communityacquired pneumonia (CAP) are admitted to an intensive care unit (ICU), and these patients account for about 10% of all medical admissions to ICUs [1,2]
Previous rules were designed to predict endpoints occurring within 30 days of emergency department (ED) presentation, which may be an excessively remote perspective, when considering both the viewpoint of the ED and ICU physicians' orientation decisions, and the potential relatedness of a late ICU transfer to physiological alterations caused by pneumonia itself
Summary
To identify risk factors for early (< three days) intensive care unit (ICU) admission of patients hospitalised with community-acquired pneumonia (CAP) and not requiring immediate ICU admission, and to stratify the risk of ICU admission on days 1 to 3. A major challenge in the management of CAP is to identify patients at risk for rapidly developing adverse medical outcomes among those presenting to the ED with no obvious reason for immediate ICU admission. Since the publication of the American Thoracic Society (ATS) guidelines in 1993, several prediction rules have been derived to identify ED patients with severe CAP, defined by adverse outcomes (including ICU admission, shock requiring vasopressors, acute respiratory failure requiring mechanical ventilation or death). Most of these prediction rules were derived in populations including patients presenting with an obvious reason for immediate ICU admission. Previous rules were designed to predict endpoints occurring within 30 days of ED presentation, which may be an excessively remote perspective, when considering both the viewpoint of the ED and ICU physicians' orientation decisions, and the potential relatedness of a late ICU transfer to physiological alterations caused by pneumonia itself
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