Reasons Why Emergency Department Providers Do Not Rely on the Pneumonia Severity Index to Determine the Initial Site of Treatment for Patients with Pneumonia

被引:63
作者
Aujesky, Drahomir [1 ]
McCausland, Julie B. [2 ]
Whittle, Jeff [5 ,6 ]
Obrosky, D. Scott [3 ,4 ]
Yealy, Donald M. [2 ]
Fine, Michael J. [3 ,4 ]
机构
[1] Univ Lausanne, Dept Med, Div Gen Internal Med, Lausanne, Switzerland
[2] Univ Pittsburgh, Dept Emergency Med, Pittsburgh, PA USA
[3] Univ Pittsburgh, Dept Med, Div Gen Internal Med, Pittsburgh, PA USA
[4] Vet Affairs Pittsburgh Healthcare Syst, Vet Affairs Ctr Hlth Equ Res & Promot, Pittsburgh, PA USA
[5] Med Coll Wisconsin, Clement J Zablocki Vet Affairs Med Ctr, Primary Care Div, Milwaukee, WI 53226 USA
[6] Med Coll Wisconsin, Dept Med, Div Gen Internal Med, Milwaukee, WI 53226 USA
基金
美国医疗保健研究与质量局;
关键词
COMMUNITY-ACQUIRED PNEUMONIA; LOW-RISK PATIENTS; RESEARCH TEAM COHORT; PREDICTION RULE; ADMISSION DECISION; CLINICAL JUDGMENT; RANDOMIZED-TRIAL; HOSPITALIZATION; OUTCOMES; CARE;
D O I
10.1086/644741
中图分类号
R392 [医学免疫学]; Q939.91 [免疫学];
学科分类号
071005 [微生物学]; 100108 [医学免疫学];
摘要
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.
引用
收藏
页码:E100 / E108
页数:9
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