Identification of Low-Risk Hospitalized Patients With Pneumonia: Projected Effects of the Guideline if Applied to Low-Risk Patients
Explicit Judgment of Quality of Care: Of those patients who were designated as at low risk, the complications were of relatively minor severity for many patients (Table 3).
Implicit Judgment: Two physicians (from a group of one pulmonologist and two general internists) reviewed the medical records of all low-risk patients who suffered any of the explicitly defined complications (life-threatening or otherwise) . Canadian pharmacy levitra The physicians independently judged that 1.8 percent (95 percent Cl 0.4 percent, 5.2 percent) of patients may have been adversely affected had they been switched from parenteral to oral antimicrobial therapy, and 6.6 percent (95 percent Cl 3.4 percent, 11.6 percent) of patients may have been adversely affected had they been discharged on the fourth hospital day. Descriptions of patient complications are as follows:
Patient 1. This patient’s systolic blood pressure transiently decreased below 100 mm Hg without symptoms or treatment.
Patient 2. This patient, who had multiple myeloma, experienced possible congestive heart failure after the third hospital day. The patient was not treated for congestive heart failure and had an uneventful recovery.
Patient 3. This 84-year-old patient required transfer to the ICU for congestive heart failure after the third hospital day. The patient experienced hypoxemia that required treatment with supplemental oxygen and hypotension that necessitated administration of catecholamines intravenously. A pulmonary artery catheter was placed. The patient survived hospitalization.
Patient 4. This patient experienced broncho-spasm and possible congestive heart failure after the third hospital day. She was treated with bronchodilators and recovered uneventfully.
Patient 5. This patient had a medical history of intravenous drug use and developed a lung abscess. She was treated with prolonged parenteral antibiotics.
Patient 6. This patient, who had underlying COPD, experienced dyspnea with hypoxemia. The patient had a deep venous thrombosis but no evidence of pulmonary embolism during the hospitalization.
Patient 7. For this patient, a diagnosis of hemolytic anemia secondary to M pneumoniae pneumonia was made after the third hospital day. Although the patient’s hematocrit value decreased to 19 percent, the patient was asymptomatic and was not treated with blood products after the third hospital day.
Patient 8. This patient had a history of COPD, and intermittent hypoxemia was noted before and after the third hospital day. She was thought to have possible congestive heart failure, as evidenced on a chest radiograph. She was not treated.
Patient 9. This 87-year-old patient was admitted to the hospital when he had pneumonia and renal failure. During his hospitalization of 9 weeks’ duration, the patient had sepsis, congestive heart failure, acute myocardial infarction, unstable atrial fibrillation, and unstable atrial flutter, and was found to have normal pressure hydrocephalus. He became unresponsive and died after a “do not resuscitate” order was made.
Patient 10. This patient experienced an asymptomatic decline in systolic blood pressure of less than 100 mm Hg. She was not treated. She also had an elective bronchoscopy at the time of admission.
Patient 11. This patient experienced transient hypoxemia after bronchoscopy (percent saturation, 81 percent). She was treated with oxygen and recovered uneventfully.
Table 3—Complications Occurring in Patients Designated as Low-Risk by the Practice Guideline
|Complication||No. of Patients|
|Change in comorbid diseases||5|
|Congestive heart failure||5|
|Altered mental status||4|
|Hypoxia (P02 <60 mm Hg)||3|
|Hypercapnia (Pcog >50 mm Hg)||1|
|Acute myocardial infarction||1|
|Unstable atrial fibrillation||1|
|Unstable atrial flutter||1|
Category: Respiratory Symptoms
Tags: antimicrobial therapy, congestive heart failure, healthcare costs, hospitalization, pneumonia