Community-acquired Pneumonia In Emergency Department Research Articles

Prognostic Prediction Value of qSOFA, SOFA, and Admission Lactate in Septic Patients with Community-Acquired Pneumonia in Emergency Department.

Background Community-acquired pneumonia (CAP) is a leading cause of sepsis and common presentation to emergency department (ED) with a high mortality rate. The prognostic prediction value of sequential organ failure assessment (SOFA) and quick SOFA (qSOFA) scores in CAP in ED has not been validated in detail. The aim of this research is to investigate the prognostic prediction value of SOFA, qSOFA, and admission lactate compared with that of other commonly used severity scores (CURB65, CRB65, and PSI) in septic patients with CAP in ED. Methods Adult septic patients with CAP admitted between Jan. 2017 and Jan. 2019 with increased admission SOFA ≥ 2 from baseline were enrolled. The primary outcome was 28-day mortality. The secondary outcome included intensive care unit (ICU) admission, mechanical ventilation, and vasopressor use. Prognostic prediction performance of the parameters above was compared using receiver operating characteristic (ROC) curves. Kaplan–Meier survival curves were compared using optimal cutoff values of qSOFA and admission lactate. Results Among the 336 enrolled septic patients with CAP, 89 patients died and 247 patients survived after 28-day follow-up. The CURB65, CRB65, PSI, SOFA, qSOFA, and admission lactate levels were statistically significantly higher in the death group (P < 0.001). qSOFA and SOFA were superior and the combination of qSOFA + lactate and SOFA + lactate outperformed other combinations of severity score and admission lactate in predicting both primary and secondary outcomes. Patients with admission qSOFA < 2 or lactate ≤ 2 mmol/L showed significantly prolonged survival than those patients with qSOFA ≥ 2 or lactate > 2 mmol/L (log-rank χ2 = 59.825, P < 0.001). The prognostic prediction performance of the combination of qSOFA and admission lactate was comparable to the full version of SOFA (AUROC 0.833 vs. 0.795, Z = 1.378, P=0.168 in predicting 28-day mortality; AUROC 0.868 vs. 0.895, Z = 1.022, P=0.307 in predicting ICU admission; AUROC 0.868 vs. 0.845, Z = 0.921, P=0.357 in predicting mechanical ventilation; AUROC 0.875 vs. 0.821, Z = 2.12, P=0.034 in predicting vasopressor use). Conclusion qSOFA and SOFA were superior to CURB65, CRB65, and PSI in predicting 28-day mortality, ICU admission, mechanical ventilation, and vasopressor use for septic patients with CAP in ED. Admission qSOFA with lactate is a convenient and useful predictor. Admission qSOFA ≥ 2 or lactate > 2 mmol/L would be very helpful in discriminating high-risk patients with a higher mortality rate.

Outcome prediction value of National Early Warning Score in septic patients with community-acquired pneumonia in emergency department: A single-center retrospective cohort study.

To evaluate the accuracy of National Early Warning Score (NEWS) in predicting clinical outcomes (28-day mortality, intensive care unit [ICU] admission, and mechanical ventilation use) for septic patients with community-acquired pneumonia (CAP) compared with other commonly used severity scores (CURB65, Pneumonia Severity Index [PSI], Sequential Organ Failure Assessment [SOFA], quick SOFA [qSOFA], and Mortality in Emergency Department Sepsis [MEDS]) and admission lactate level. Adult patients diagnosed with CAP admitted between January 2017 and May 2019 with admission SOFA ≥2 from baseline were enrolled. Demographic characteristics were collected. The primary outcome was the 28-day mortality after admission, and the secondary outcome included ICU admission and mechanical ventilation use. Outcome prediction value of parameters above was compared using receiver operating characteristics (ROC) curves. Cox regression analyses were carried out to determine the risk factors for the 28-day mortality. Kaplan-Meier survival curves were plotted and compared using optimal cut-off values of qSOFA and NEWS. Among the 340 enrolled patients, 90 patients were dead after a 28-day follow-up, 62 patients were admitted to ICU, and 84 patients underwent mechanical ventilation. Among single predictors, NEWS achieved the largest area under the receiver operating characteristic (AUROC) curve in predicting the 28-day mortality (0.861), ICU admission (0.895), and use of mechanical ventilation (0.873). NEWS+lactate, similar to MEDS+lactate, outperformed other combinations of severity score and admission lactate in predicting the 28-day mortality (AUROC 0.866) and ICU admission (AUROC 0.905), while NEWS+lactate did not outperform other combinations in predicting mechanical ventilation (AUROC 0.886). Admission lactate only improved the predicting performance of CURB65 and qSOFA in predicting the 28-day mortality and ICU admission. NEWS could be a valuable predictor in septic patients with CAP in emergency departments. Admission lactate did not predict well the outcomes or improve the severity scores. A qSOFA ≥2 and a NEWS ≥9 were strongly associated with the 28-day mortality, ICU admission, and mechanical ventilation of septic patients with CAP in the emergency departments.

Comparison of emergency chest ultrasound with radiography in the diagnosis of community-acquired pneumonia in Emergency Department

Comparison of emergency chest ultrasound with radiography in the diagnosis of community-acquired pneumonia in Emergency Department

Stratified and prognostic value of admission lactate and severity scores in patients with community-acquired pneumonia in emergency department: A single-center retrospective cohort study.

Background:Community-acquired pneumonia (CAP) is a potentially life-threatening condition. The aim of this study is to investigate the stratified and prognostic value of admission lactate and severity scores (confusion, urea >7 mmol/L, respiratory rate ≥30/min, blood pressure <90 mm Hg systolic and/or ≤60 mm Hg diastolic, and age ≥65 years [CURB65], pneumonia severity index [PSI], sequential organ failure assessment [SOFA], qSOFA) in patients with CAP in emergency department.Methods:Adult patients diagnosed with CAP admitted between January 2017 and January 2019 were enrolled and divided into severe CAP (SCAP) group and nonSCAP (NSCAP) group according to international guidelines, death group, and survival group according to 28-day prognosis. Predicting performance of parameters above was compared using receiver operating characteristic curves and logistic regression model. Cox proportional hazard regression model was used to identify variables independently associated with 28-day mortality.Results:A total of 350 patients with CAP were enrolled. About 196 patients were classified as SCAP and 74 patients died after a 28-day follow-up. The levels of CURB65, PSI, SOFA, qSOFA, and admission lactate were higher in the SCAP group and death group. SOFA showed advantage in predicting SCAP, while qSOFA is superior in predicting 28-day mortality. The combination of SOFA and admission lactate outperformed other combinations in predicting SCAP, and the combination of qSOFA and lactate showed highest superiority over other combinations in predicting 28-day mortality.Conclusion:The SOFA is a valuable predictor for SCAP and qSOFA is superior in predicting 28-day mortality. Combination of qSOFA and admission lactate can improve the predicting performance of single qSOFA.

Validity of SMART-COP score in prognosis and severity of community acquired pneumonia in the emergency department

BackgroundDetermining prognosis in community acquired pneumonia (CAP), is very important. Many scores are introduced up to now for prediction of pneumonia prognosis like SMART-COP. ObjectiveTo evaluate validity of SMART-COP score in prognosis and severity of CAP in emergency department (ED). MethodsAll patients older than 18 years old with clinical suspicion of CAP (meeting the inclusion criteria), were enrolled in our study. In this prospective study, patients were admitted to the ED of a tertiary referral center. Hospital length of stay, rate of intensive care unit (ICU) admission, mortality rate, number of intensive respiratory or vasopressor support (IRVS) use, patients' SMART-COP scores and all demographic data were recorded. Validity of SMART-COP in the prediction of IRVS rate and its correlation with other variables were determined. ResultsIn this study, 47.6% and 52.4% of patients were females and males respectively. The mean age of patients was 68.13 ± 16.60 years old. The mean hospital length of stay was 13.49 ± 5.62 days. Of all patients entered in our study, 55 cases (38.5%) needed ICU admission, 29 cases (20.3%) were expired within 1 month and 44 cases (30.8%) needed IRVS during their treatment. SMART-COP ≥5 (high risk CAP) accurately predicted the rate of ICU admission, one-month mortality and IRVS need (p-value = 0.001). ConclusionsSMART-COP≥5 had a high sensitivity and specificity in the prediction of patients' prognosis with severe CAP in the ED.

Risk stratification and prediction value of procalcitonin and clinical severity scores for community-acquired pneumonia in ED

ObjectiveCommunity-acquired pneumonia (CAP) is a common presentation to the emergency department (ED) and has high mortality rates. The aim of our study is to investigate the risk stratification and prognostic prediction value of precalcitonin (PCT) and clinical severity scores on patients with CAP in ED. Methods226 consecutive adult patients with CAP admitted in ED of a tertiary teaching hospital were enrolled. Demographic information and clinical parameters including PCT levels were analyzed. CURB65, PSI, SOFA and qSOFA scores were calculated and compared between the severe CAP (SCAP) and non-severe CAP (NSCAP) group or the death and survival group. Receiver-operating characteristic (ROC) curves for 28-day mortality were calculated for each predictor using cut-off values. Logistic regression models and area under the curve (AUC) analysis were performed to compare the performance of predictors. ResultsFifty-one patients were classified as SCAP and forty-nine patients died within 28days. There was significant difference between either SCAP and NSCAP group or death and survival group in PCT level and CURB65, PSI, SOFA, qSOFA scores (p < 0.001). The AUCs of the PCT and CURB65, PSI, SOFA and qSOFA in predicting SCAP were 0.875, 0.805, 0.810, 0.852 and 0.724, respectively. PCT is superior in predicting SCAP and the models combining PCT and SOFA demonstrated superior performance to those of PCT or the CAP severity score alone. The AUCs of the PCT and CURB65, PSI, SOFA and qSOFA in predicting 28-day mortality were 0.822, 0.829, 0.813, 0.913 and 0.717, respectively. SOFA achieved the highest AUC and the combination of PCT and SOFA had the highest superiority over other combinations in predicting 28-day mortality. ConclusionSerum PCT is a valuable single predictor for SCAP. SOFA is superior in prediction of 28-day mortality. Combination of PCT and SOFA could improve the performance of single predictors. More further studies with larger sample size are warranted to validate our results.

Evaulation of PSİ and CURB-65 scoring systems which patients were diagnosed as community-acquired pneumonia in emergency department

Amac: Bu calismadaki amacimiz, hastanemiz acil servisine basvuran toplum kokenli pno moni tan ili hastalarda, pnomoni ciddiyet indeksi (PSI) ve CURB-65 pnomoni skorlama sistemlerinin hastaneye yatis ya da taburculuk acisindan uygunluklarinin karsilastirilmasidir. Yontem: Bu retrospektif calismaya Haziran 2013-Haziran 2014 tarihleri arasinda acil servise bas vuran ve pno moni tanisi alan 150 olgu dahil edildi. Olgulari n demografik ozellikleri, klinik, radyolojik ve laboratuar bulgulari kayit edildi. Tum olgular PSI ve CURB-65 skorlamasina gore gruplandirildi ve hastaneye yatis ya da taburculuk acisindan uygunluklari incelendi. Bulgular: Calismaya yas ortalamalari 69.15 ± 13.34 (min: 19; max: 92) olan 47 (%31.3) kadin, 103 (%68.7) erkek, toplam 150 olgu dahil edildi. Toplam 109 olguda CURB-65 ile PSI arasinda yatarak tedavi gerekliligi acisindan uyumluluk mevcuttu (κ=0,602, p<0,001). Yogun bakim yatis olasiligi ele alindiginda, PSI, CURB-65 ’ e gore daha anlamli bulundu (p=0,011, p=0,045, p<0, 05). Sonuc: Guncel pratikte kullanilmakta olan iki pno moni ag irlik gruplamasinin (CURB- 65, PSI) hastaneye yatarak tedavi endikasyonunu degerlendirmek acisindan birbirleri ile korele oldugu goruldu . CURB-65, deg erlendirme kriterlerinin az olmasi ve bunlarin birinci basamak merkezlerde dahi kolaylikla uygulanabilecek kriterler olmasi nedeni ile pnomoni olgularinda yatarak tedavi gereklilig ini deg erlendirmede tercih edilecek yontem olabilir.

EMERGENCY DEPARTMENT RE-ATTENDANCES AND TREATMENT MODIFICATIONS IN YOUNG CHILDREN WITH UNCOMPLICATED COMMUNITY-ACQUIRED PNEUMONIA: A PERUKI STUDY

Objectives & BackgroundData on the rate of antibiotic retreatment in children with uncomplicated community-acquired pneumonia (CAP) are lacking. We conducted a service evaluation of CAP management to review assumptions for...

IMPACT OF POINT OF CARE CRP TESTING ON THE MANAGEMENT OF PATIENTS WITH SUSPECTED COMMUNITY ACQUIRED PNEUMONIA IN THE ED

Objectives & BackgroundThe World Health Organisation has identified antimicrobial resistance as “an increasingly serious threat to global public health that requires action across all government sectors and society”, and state...

37 Emergency Department Hospitalization Practices for Community-Acquired Pneumonia Encounters: Validating CURB-65 for Discharged Patients

Pneumonia accounts for over 1.2 million US hospitalizations annually resulting in $10.2 billion in health care costs. Unnecessary hospitalizations put patients at risk and strain the limited resources of an already taxed medical system. Currently, tools to assess pneumonia severity have limited applicability to emergency department (ED) disposition decisions because they were developed using only data from patients admitted to the hospital. This study describes current ED admission practices for patients with community-acquired pneumonia (CAP) based on the CURB-65 severity index, and reports on CURB-65’s ability to predict 30-day mortality for a cohort of patients discharged and hospitalized from the ED. A retrospective, observational study of all adult CAP encounters in 14 community EDs from July 2009 to June 2012. We calculated CURB-65 scores based on the established severity scoring system (0-5) to describe all encounters, as well as stratified by those hospitalized and discharged. Each score was used as a cut-off to calculate sensitivity, specificity, positive predictive value, and negative predictive value for predicting 30-day mortality. We described the use of hospitalization for ED CAP encounters and identified discharged patients returning for admission within 7 days. The sample included 21,183 ED encounters for CAP (7,952 discharged and 13,231 admitted). The C-statistic describing the accuracy of CURB-65 at predicting 30-day mortality in the full sample was 0.761 (95% CI, 0.747-0.774). Among patients discharged from the ED it performed better (0.864, 95% CI, 0.821-0.906) than for those admitted from the ED (0.689, 95% CI, 0.672-0.705). Among all encounters a CURB-65 threshold ≥1 was 92.8% sensitive and 38.0% specific with a 99.0% NPV. Among all encounters, 62.5% were admitted, 36.2% of those at lowest risk (CURB-65=0). Overall, discharged CAP patients had a 5.7% chance of returning for hospital admission within 7 days of the encounter. When stratified by CURB-65 score, 4.2%, 7.7%, 7.5%, and 12.8% were hospitalized within 7 days for scores 0-2 and ≥ 3 respectively. If a low-risk threshold of CURB-65 ≤ 1 had been the only factor used to determine ED discharge vs. admission, then only 34.3% of patients (versus 62.5%) would have been hospitalized. This would have avoided 6,936 (52.4%) of our observed low-risk admissions, and conversely increased admissions for high-risk (CURB-65 ≥ 2) by 970 admissions (7.3%), resulting in a net decrease of 5,966 (45.1%) hospitalizations. CURB-65 has very good accuracy for predicting 30-day mortality for patients with CAP discharged from the ED, even better than previous reports of hospitalized cohorts (C-statistic 0.87 vs 0.80). This severity tool may be used when assessing ED patients with CAP to assist providers and patients with disposition decisions. Discharging the lowest risk patients could provide substantial savings to the US health system while maintaining acceptable patient safety.

Improved Management of Community-Acquired Pneumonia in the Emergency Department

ObjectivesTo determine the impact of implementing clinical practice guidelines (CPGs) in the treatment of community-acquired pneumonia (CAP) in the emergency department (ED) by analyzing case management decisions (admission or discharge, appropriateness and timeliness of antibiotic therapy, complementary tests) and the consequent results (clinical stabilization time, length of hospital stay, re-admission to ED and mortality). MethodsA prospective, observational, descriptive, comparative study carried out from 1st January 2008 to 1st August 2009 in two phases: before and after the implementation of the “Management of CAP in ED” SEMES-SEPAR (Spanish Society of Emergency Medicine – Spanish Society of Pneumology and Thoracic Surgery) clinical practice guidelines from 2008. Two hundred adult patients treated in the ED with a diagnosis of CAP were included in the study, both in the pre-intervention and post-intervention groups. ResultsThe application of the guidelines increased the administration of early and appropriate antibiotic therapy (P<.001) and shortened both the total antibiotic therapy (P<.001) and the intravenous antibiotic therapy (P=.042) times. Time to clinical stabilization (P=.027), length of hospital stay (1.14 days, P=.01), intra-hospital mortality (P=.004) and total 30-day mortality (P=.044) were all reduced. Assessment with the Pneumonia Severity Index (PSI) and biomarkers aided in appropriate decision-making concerning admission/discharge (P<.001). ConclusionsThe implementation of the SEMES-SEPAR 2008 guidelines, along with the use of PSI and biomarkers, significantly improved the entire treatment process of CAP. This benefitted both patients and the system by reducing mortality and improving the results of other patient management factors.

Mejora del manejo de la neumonía adquirida en la comunidad en el servicio de urgencias

ObjectivesTo determine the impact of implementing clinical practice guidelines (CPGs) in the treatment of community-acquired pneumonia (CAP) in the emergency department (ED) by analyzing case management decisions (admission or discharge, appropriateness and timeliness of antibiotic therapy, complementary tests) and the consequent results (clinical stabilization time, length of hospital stay, re-admission to ED and mortality). MethodsA prospective, observational, descriptive, comparative study carried out from 1st January 2008 to 1st August 2009 in two phases: before and after the implementation of the «Management of CAP in ED» SEMES-SEPAR (Spanish Society of Emergency Medicine - Spanish Society of Pneumology and Thoracic Surgery) clinical practice guidelines from 2008. Two hundred adult patients treated in the ED with a diagnosis of CAP were included in the study, both in the pre-intervention and post-intervention groups. ResultsThe application of the guidelines increased the administration of early and appropriate antibiotic therapy (P<.001) and shortened both the total antibiotic therapy (P<.001) and the intravenous antibiotic therapy (P=.042) times. Time to clinical stabilization (P=.027), length of hospital stay (1.14 days, P=.01), intra-hospital mortality (P=.004) and total 30-day mortality (P=.044) were all reduced. Assessment with the Pneumonia Severity Index (PSI) and biomarkers aided in appropriate decision-making concerning admission/discharge (P<.001). ConclusionsThe implementation of the SEMES-SEPAR 2008 guidelines, along with the use of PSI and biomarkers, significantly improved the entire treatment process of CAP. This benefitted both patients and the system by reducing mortality and improving the results of other patient management factors.

Outcomes of Early, Late, and No Admission to the Intensive Care Unit for Patients Hospitalized with Community‐acquired Pneumonia

The objective was to compare outcomes associated with early, late, and no admission to the intensive care unit (ICU) for patients hospitalized with community-acquired pneumonia (CAP). This was a post hoc analysis of the original data from the Emergency Department Community-Acquired Pneumonia (EDCAP) and Pneumocom-1 prospective multicenter cohort studies of adult patients hospitalized with CAP. Propensity score-adjusted analysis was used to compare 28-day mortality and hospital length of stay (LOS) for 199, 144, and 2,215 patients with early (i.e., ICU admission on the day of emergency department [ED] presentation), late, and no ICU admission. Unadjusted 28-day mortality rates were 13.1, 19.4, and 5.7% for early, late, and no ICU admissions, respectively (p < 0.001). After adjusting for quintile of propensity score, the odds of 28-day mortality were higher for late ICU admissions relative to early ICU admissions (odds ratio [OR] = 2.63; 95% confidence interval [CI] = 1.42 to 4.90), and no ICU admissions (OR = 3.40; 95% CI = 2.11 to 5.48), but did not differ between early and no ICU admissions (OR = 1.29; 95% CI = 0.79 to 2.09). The median hospital LOS was 10 days for early (interquartile range [IQR] = 7 to 18), 15 days for late (IQR 9 to 23), and 6 days (IQR 4 to 9) for no ICU admissions (p < 0.001). This study suggests that late but not early admission to the ICU is associated with higher 28-day mortality for patients hospitalized with CAP. Patients admitted to the ICU have longer hospital LOS in comparison to those managed on the wards, particularly if they are admitted late to the ICU.

A quality improvement initiative to improve adherence to national guidelines for empiric management of community-acquired pneumonia in emergency departments

The objective of this study was to improve the concordance of community-acquired pneumonia management in Australian emergency departments with national guidelines through a quality improvement initiative promoting concordant antibiotic use and use of a pneumonia severity assessment tool, the pneumonia severity index (PSI). and Drug use evaluation, a quality improvement methodology involving data collection, evaluation, feedback and education, was undertaken. Educational interventions included academic detailing, group feedback presentations and prescribing prompts. Data were collected on 20 consecutive adult community-acquired pneumonia emergency department presentations by each hospital for each of three audits. Two process indicators measured the impact of the interventions: documented PSI use and concordance of antibiotic prescribing with guidelines. Comparisons were performed using a Chi-squared test. Thirty-seven hospitals, including public, private, rural and metropolitan institutions, participated. Twenty-six hospitals completed the full study (range: 462-518 patients), incorporating two intervention phases and subsequent follow-up audits. The baseline audit of community-acquired pneumonia management demonstrated that practice was varied and mostly discordant with guidelines. Documented PSI use subsequently improved from 30/518 (6%, 95% confidence interval [CI] 4-8) at baseline to 125/503 (25%, 95% CI 21-29; P < 0.0001) and 102/462 (22%, 95% CI 18-26; P < 0.0001) in audits two and three, respectively, while concordant antibiotic prescribing improved from 101/518 (20%, 95% CI 16-23) to 132/462 (30%, 95% CI 26-34; P < 0.0001) and 132/462 (29%, 95% CI 24-33; P < 0.001), respectively. Improved uptake of guideline recommendations for community-acquired pneumonia management in emergency departments was documented following a multi-faceted education intervention.

Identification of 90% of Patients Ultimately Diagnosed With Community-Acquired Pneumonia Within Four Hours of Emergency Department Arrival May Not Be Feasible

We determine whether it is feasible to identify 90% of emergency department (ED) patients who subsequently receive a hospital discharge diagnosis of community-acquired pneumonia using the current Joint Commission on Accreditation of Healthcare Organizations (JCAHO)/Centers for Medicare and Medicaid Services (CMS) community-acquired pneumonia core measures criteria. This was a retrospective case series in a university tertiary care ED. From a random sample of patients discharged from the hospital between January and December 2005 who were eligible for JCAHO/CMS community-acquired pneumonia antibiotic timing measure PN-5b, we identified the proportion of patients admitted through the ED who received antibiotics more than 4 hours after hospital arrival (outliers). Medical records of outliers were reviewed to determine whether they received a final ED community-acquired pneumonia diagnosis. Presenting characteristics of outliers with and without final ED community-acquired pneumonia diagnoses were compared to determine feature(s) that might explain failure to diagnose community-acquired pneumonia in the ED. Of 152 eligible ED community-acquired pneumonia patients, 53 (34.9%) were identified as outliers. Thirty-one of the outliers did not have a final ED community-acquired pneumonia diagnosis. Thus, at least 20.4% (95% confidence interval [CI] 14.3% to 27.7%) of all ED community-acquired pneumonia patients did not have an ED community-acquired pneumonia diagnosis. Of outliers without an ED community-acquired pneumonia diagnosis, 43.3% had an abnormal chest radiograph compared with 95% with an ED community-acquired pneumonia diagnosis (odds ratio 24.8; 95% CI 3.63 to infinity). It may not be possible to identify 90% of hospitalized patients with a discharge diagnosis of community-acquired pneumonia during their ED assessment by using the current JCAHO/CMS criteria. It may therefore be unrealistic to expect that 90% of such patients will have antibiotics delivered within 4 hours of hospital presentation. A more realistic performance standard for antibiotic administration should be established or case definitions modified to include only patients with a final ED community-acquired pneumonia diagnosis or objective clinical and radiographic evidence.

Use of intravenous antibiotics for the treatment of community-acquired pneumonia in the emergency department

To determine the extent of intravenous (IV) antibiotic use for community-acquired pneumonia (CAP) in emergency departments, the practice patterns in seven emergency departments serving the adult residents of one Canadian city were observed. An observational study of nonhospitalized adults diagnosed with CAP in seven emergency departments was conducted between November 15, 2000, and November 19, 2002. Data related to antibiotic treatment of CAP administered in the emergency department and patient-specific characteristics potentially predictive of IV treatment were collected. A total of 3512 subjects were identified, of which 4.9% received treatment with IV antibiotics. Cefuroxime and levofloxacin were the most commonly used IV agents, while orally-treated subjects primarily received a macrolide or levofloxacin. The proportion of subjects receiving IV antibiotics differed significantly among the seven sites: 1.4%-10.6% (p > 0.0001). Logistic regression identified a number of independent predictors of receipt of IV antibiotics including risk class, temperature, respiratory rate, study year, presence of vomiting, prior antibiotic treatment, and personal care home residence. However, these predictors did not explain intersite differences. Only a small proportion of patients (4.9%) presenting to the emergency department with CAP received IV antibiotics. While patient demographics and severity indicators influenced the likelihood of receipt of IV antibiotics, considerable intersite variation existed, despite adjustment for such factors.

The emergency department community-acquired pneumonia trial*1Methodology of a quality improvement intervention

The emergency department community-acquired pneumonia trial*1Methodology of a quality improvement intervention

The emergency department community-acquired pneumonia trial: Methodology of a quality improvement intervention.

Community-acquired pneumonia causes more than 4 million episodes of illness each year and has high morbidity, mortality, and total cost of care. Nationwide, nearly 75% of community-acquired pneumonia patients are initially evaluated and treated in hospital-based emergency departments (EDs). Substantial variation exists in illness severity assessment, hospital admission decisions, and performance of recommended processes of care. We designed an ED-based quality improvement trial focused on the initial care of patients with community-acquired pneumonia. We used the Pneumonia Severity Index and level of arterial oxygenation to identify patients at low risk for 30-day mortality and to guide admission decisionmaking. We assessed the performance of recommended "best practices," consisting of assessment of arterial oxygenation, the collection of blood cultures for inpatients, and the timely initiation of appropriate empiric antibiotic therapy for inpatients and outpatients. We conducted a 32-site, cluster-randomized trial in Pennsylvania and Connecticut, comparing the effectiveness and safety of 3 guideline implementation strategies of increasing intensity. The multifaceted implementation plans were carried out in conjunction with each state's quality improvement organization. This article describes the background, objectives, and methodology of this trial to translate evidence-based knowledge on the quality and efficiency of care for community-acquired pneumonia into clinical practice.