Admission is not always necessary for patients with community-acquired pneumonia in risk classes IV and V diagnosed in the emergency room

OBJECTIVE: To determine the factors that allow patients with community-acquired pneumonia who are at high risk of mortality (risk classes IV and V) to be treated at home. DESIGN: A prospective, observational study. SETTING: Six hospitals and one free-standing emergency room in Edmonton, Alberta. PARTICIPANTS: The present study included 2354 patients in risk classes IV and V who had a diagnosis of pneumonia made by an emergency room physician or an internist. MEASUREMENTS: Symptoms, signs and laboratory findings, as well as outcome measures of length of stay and mortality. RESULTS: Of the total study group, 319 of the patients (13.5%) were treated on an ambulatory basis. Factors predictive of admission were definite or possible pneumonia on chest radiograph as read by a radiologist, functional impairment, altered mental status, substance abuse, psychiatric disorder, abnormal white blood cell Count, abnormal lymphocyte Count, oxygen saturation less than 90% and antibiotic administration in the week before admission. If chest pain was present, admission was less likely. Only two of the 319 patients required subsequent: admission (both had positive blood Cultures) and only two died. CONCLUSIONS: A substantial number of patients in risk classes IV and V can be safely treated at home. Factors that help clinicians to select this subset of patients are discussed.