Clinical research study
Low-risk patients admitted with community-acquired pneumonia

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Abstract

Purpose

To describe the natural history of community-acquired pneumonia in the subset of a large cohort of patients at low risk for mortality who were admitted to the hospital.

Methods

Prospective observational study of all patients at low risk for mortality (risk classes I and II) who presented to 6 hospitals and 1 emergency department in Edmonton, Alberta, Canada with a diagnosis of possible community-acquired pneumonia from November 15, 2000, to November 14, 2002.

Results

A total of 586/3065 (19.1%) low-risk patients (Fine criteria) were admitted, 48.4% of whom stayed more than 5 days. Multivariate analysis revealed that patients who were admitted were more likely to be female, to have presented at Site B, which serves an inner city population, to have diminished premorbid functional status, to have comorbidities likely to be made worse by pneumonia (chronic obstructive pulmonary disease, asthma, heart disease, inflammatory bowel disease), and to suffer from substance abuse or psychiatric illness. A respiratory rate of ≥28 breaths per minute, and symptoms of shaking chills, shortness of breath, nausea or diarrhea were the remaining factors predicting admission. Nineteen percent of the patients suffered one or more complications, the most serious of which was progression of the pneumonia, resulting in respiratory failure necessitating mechanical ventilation in 2.4% and empyema in 1.4%. Four patients had lung cancer, and 1 had cancer of the vocal cords. Thirty-one percent of those who were admitted were still unable to eat or drink enough to maintain hydration by hospital day 5 or on discharge day.

Conclusions

One in 5 patients at low risk for mortality were admitted to the hospital and half stayed more than 5 days; 19% suffered 1 or more complications. Our data emphasize the need for better rules to guide the admission decision and the importance of physician judgment in this decision.

Section snippets

Study sites

This study involved all 6 hospitals in the Edmonton area and one free-standing emergency department. This study was approved by the research ethics committee at the University of Alberta.

Development of pneumonia pathway

A multi-disciplinary team developed a comprehensive pathway for the management of community-acquired pneumonia.7 The pathway consisted of an admission guideline (which was not expected to be a substitute for the physician’s judgement),4 preprinted orders covering routine aspects of care, an algorithm for

Results

During the 2 years of the study, 3065 patients in risk classes I and II were evaluated in the emergency departments of the participating hospitals. Of these, 586 (19.1%) patients were admitted. The admitted and the ambulatory patients are compared in Table 1. The admitted patients were older, 46.5 years of age versus 42.9 years, and were more likely to be female.

There was a 2-fold variation in the admission rate of low-risk patients at the 6 hospitals, ranging from 14.8% to 29.3%. The latter

Discussion

The site of care (home, hospital ward, or intensive care unit) is probably the single most important decision in the management of patients with community-acquired pneumonia.12 There are now several prediction rules or algorithms available to help the physician make this choice by stratifying the patients into those who are at low risk for mortality.4, 5, 6 We found that 19% of patients in risk classes I and II were admitted to hospital, with almost half staying 5 days or more, and 20% suffered

Acknowledgments

We thank the following community-acquired pneumonia pathway nurses: JoAnne de Jager, Linda Gardner, Lynne Korobanik, Tammy Pfeiffer, Cynthia Proskow, Sue Marshall, Nancy Baker, Nan Horne, Fredrika Herbert, and Carol Mangan. The staff of the Epidemiology Coordinating and Research Centre carried out data management for the project.

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    Supported by an independent research establishment grant from the Alberta Heritage Foundation for Medical Research and by grants in aid from Capital Health, Abbott Canada, Pfizer Canada, and Jannsen-Ortho Canada.

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