Identification of Low-Risk Hospitalized Patients With Pneumonia: Methods
Description of Institution
The study was performed at Cedars-Sinai Medical Center, a large teaching community hospital that primarily serves West Los Angeles. The majority of hospitalized patients are cared for by physicians in private practice.
Description of Patients
The inclusionary criteria for pneumonia were the presence of an infiltrate on the chest radiograph and at least one of the major or two of the minor criteria given heretofore: major criteria—cough, sputum production, or history of fever; minor criteria—dyspnea, pleuritic chest pain, pulmonary consolidation on physical examination, or WBC count greater than 12,000/ml. Patients with Mycobacterium tuberculosis infection, human immunodeficiency virus infection, known lung cancer, and those patients less than 18 years of age were excluded from the study.
The etiology of pneumonia was assigned using the method described by Fang and colleagues.
The practice guideline was derived from the medical literature and was formalized by the consensus study group that included a pulmonologist, an infectious disease consultant, and two general internists. Canadian health care mall in detail Patients who did not have (1) obvious reasons for continued hospitalization on the third hospital day, (2) a high-risk pneumonia pathogen (although patients with Cram-negative bacillary pneumonia were included), or (3) a life-threatening complication within the first 3 days of hospitalization were classified as at low risk according to the contents of the practice guideline. Absence of the following criteria implied that the patient was at low risk. The guideline is as follows:
1. Obvious reason for continued hospitalization.
Systolic blood pressure less than 100 mm Hg; dehydration as documented by hypernatremia (Na >155 mmol/L), blood urea nitrogen to creatinine ratio greater than 20:1, or orthostatic systolic blood pressure changes greater than 20 mm Hg; acute changes in mentation; hypoxia (room air arterial blood gas saturation <90 percent or P02 <55 mm Hg); acute respiratory acidosis with pH less than 7.30; observed inability to take medications or fluids orally; metastatic infection sites such as meningitis; or unstable comorbid diseases.
2. High risk pneumonia pathogen.
Staphylococcus aureus, aspiration pneumonia, postobstructive pneumonia, mycobacterial pneumonia, and fungal pneumonia.
3. Life-threatening complication during hospitalization. Acute myocardial infarction, ventricular fibrillation, ventricular tachycardia, asystole, complete heart block, new or unstable atrial fibrillation, new or unstable atrial flutter, supraventricular tachycardia, pneumothorax, congestive heart failure (new onset or worsening of chronic congestive heart failure).
These low-risk patients were considered potentially suitable for conversion to oral antimicrobial agents on the third hospital day and for discharge on the fourth hospital day.
Category: Respiratory Symptoms
Tags: antimicrobial therapy, congestive heart failure, healthcare costs, hospitalization, pneumonia