Reasons why emergency department providers do not rely on the pneumonia severity index to determine the initial site of treatment for patients with pneumonia.

BACKGROUND Many emergency department (ED) providers do not follow guideline recommendations for the use of the pneumonia severity index (PSI) to determine the initial site of treatment for patients with community-acquired pneumonia (CAP). We identified the reasons why ED providers hospitalize low-risk patients or manage higher-risk patients as outpatients. METHODS As a part of a trial to implement a PSI-based guideline for the initial site of treatment of patients with CAP, we analyzed data for patients managed at 12 EDs allocated to a high-intensity guideline implementation strategy study arm. The guideline recommended outpatient care for low-risk patients (nonhypoxemic patients with a PSI risk classification of I, II, or III) and hospitalization for higher-risk patients (hypoxemic patients or patients with a PSI risk classification of IV or V). We asked providers who made guideline-discordant decisions on site of treatment to detail the reasons for nonadherence to guideline recommendations. RESULTS There were 1,306 patients with CAP (689 low-risk patients and 617 higher-risk patients). Among these patients, physicians admitted 258 (37.4%) of 689 low-risk patients and treated 20 (3.2%) of 617 higher-risk patients as outpatients. The most commonly reported reasons for admitting low-risk patients were the presence of a comorbid illness (178 [71.5%] of 249 patients); a laboratory value, vital sign, or symptom that precluded ED discharge (73 patients [29.3%]); or a recommendation from a primary care or a consulting physician (48 patients [19.3%]). Higher-risk patients were most often treated as outpatients because of a recommendation by a primary care or consulting physician (6 [40.0%] of 15 patients). CONCLUSION ED providers hospitalize many low-risk patients with CAP, most frequently for a comorbid illness. Although higher-risk patients are infrequently treated as outpatients, this decision is often based on the request of an involved physician.

[1]  D. Davis,et al.  Clinical judgment versus the Pneumonia Severity Index in making the admission decision. , 2008, The Journal of emergency medicine.

[2]  J. Maurer.  Factors Associated with the Hospitalization of Low-risk Patients with Community-acquired Pneumonia in a Cluster-Randomized Trial , 2008 .

[3]  K. A. Cullen,et al.  National Hospital Discharge Survey: 2005 annual summary with detailed diagnosis and procedure data. , 2007, Vital and health statistics. Series 13, Data from the National Health Survey.

[4]  M. Fine,et al.  Comparison of outcomes for low-risk outpatients and inpatients with pneumonia: A propensity-adjusted analysis. , 2007, Chest.

[5]  Michael J Fine,et al.  Routine use of the Pneumonia Severity Index for guiding the site-of-treatment decision of patients with pneumonia in the emergency department: a multicenter, prospective, observational, controlled cohort study. , 2007, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[6]  M. Fine,et al.  Factors associated with the hospitalization of low-risk patients with community-acquired pneumonia in a cluster-randomized trial , 2006, Journal of General Internal Medicine.

[7]  J. Maurer.  Outpatient Care Compared With Hospitalization for Community-Acquired Pneumonia: A Randomized Trial in Low-Risk PatientsCarratalà J, Fernández-Sabé N, Ortega L, et al (Univ of Barcelona; SCIAS-Hosp de Barcelona) Ann Intern Med 142:165–172, 2005§ , 2006 .

[8]  M. Fine,et al.  Effect of Increasing the Intensity of Implementing Pneumonia Guidelines , 2005, Annals of Internal Medicine.

[9]  M. M. van der Eerden,et al.  Prospective evaluation of pneumonia severity index in hospitalised patients with community-acquired pneumonia. , 2004, Respiratory medicine.

[10]  Graves Ej,et al.  National Hospital Discharge Survey , 2004 .

[11]  M. Fine,et al.  The emergency department community-acquired pneumonia trial: Methodology of a quality improvement intervention. , 2004, Annals of emergency medicine.

[12]  C. Goss,et al.  Cost and incidence of social comorbidities in low-risk patients with community-acquired pneumonia admitted to a public hospital. , 2003, Chest.

[13]  J. Ramirez,et al.  Hospitalization for community-acquired pneumonia: the pneumonia severity index vs clinical judgment. , 2003, Chest.

[14]  A. Bilbao,et al.  A prediction rule to identify allocation of inpatient care in community-acquired pneumonia , 2003, European Respiratory Journal.

[15]  Michael J Fine,et al.  Testing Strategies in the Initial Management of Patients with Community-Acquired Pneumonia , 2002, Annals of Internal Medicine.

[16]  M. Fine,et al.  Causes of death for patients with community-acquired pneumonia: results from the Pneumonia Patient Outcomes Research Team cohort study. , 2002, Archives of internal medicine.

[17]  O. Baud,et al.  Hospitalization Decision for Ambulatory Patients with Community-Acquired Pneumonia: A Prospective Study with General Practitioners in France , 2001, Infection.

[18]  J. Dorca,et al.  Etiology, reasons for hospitalization, risk classes, and outcomes of community-acquired pneumonia in patients hospitalized on the basis of conventional admission criteria. , 2001, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[19]  T. Dieterle,et al.  Community-acquired pneumonia--which patients are hospitalised? , 2001, Swiss medical weekly.

[20]  T. Marras,et al.  Applying a prediction rule to identify low-risk patients with community-acquired pneumonia. , 2000, Chest.

[21]  T. Marrie,et al.  A controlled trial of a critical pathway for treatment of community-acquired pneumonia. CAPITAL Study Investigators. Community-Acquired Pneumonia Intervention Trial Assessing Levofloxacin. , 2000, JAMA.

[22]  D. Singer,et al.  Understanding physician adherence with a pneumonia practice guideline: effects of patient, system, and physician factors. , 2000, Archives of internal medicine.

[23]  Inger,et al.  A prediction rule to identify low-risk patients with community-acquired pneumonia. , 1997, The New England journal of medicine.

[24]  M. Fine,et al.  The Cost of Treating Patients with Community-Acquired Pneumonia , 1999 .

[25]  D. Singer,et al.  Safely increasing the proportion of patients with community-acquired pneumonia treated as outpatients: an interventional trial. , 1998, Archives of internal medicine.

[26]  M. Fine,et al.  The hospital discharge decision for patients with community-acquired pneumonia. Results from the Pneumonia Patient Outcomes Research Team cohort study. , 1997, Archives of internal medicine.

[27]  M. Fine,et al.  The hospital admission decision for patients with community-acquired pneumonia. Results from the pneumonia Patient Outcomes Research Team cohort study. , 1997, Archives of internal medicine.

[28]  A. Detsky,et al.  Preferences for home vs hospital care among low-risk patients with community-acquired pneumonia. , 1996, Archives of internal medicine.

[29]  M. A. Judson.  Clinical Judgment , 1994, Annals of Internal Medicine.