Impact of measuring pneumonia severity index (PSI) in the management of community-acquired pneumonia in the Emergency Department
Eduardo Esteban-Zubero, Marta Rubio-Gómez, Alberto García-Noain, Beatriz Sierra-Bergua, Joaquín Gómez-Bitrian, Francisco José Ruiz-Ruiz
Abstract
Community-acquired pneumonia is a prevalent disease in the Emergency Department (ED). The literature reveals that clinical practice could not be related with guideline recommendations. The aim of this study is to determine the impact of the implementation of the recommendations of the Spanish Society of Emergency Medicine in the Hospital Clínico Universitario Lozano Blesa (Zaragoza) ED in the management of community-acquired pneumonia. Use of Pneumonia Severity Index (PSI) estimation was used to assess the adherence. This study was carried out from December 2014 to February 2015. Data was compared with the previous two months. The indicators management (discharge or admission decision, adequacy and anti-biotherapy) as well as the incidence of PSI estimation before and after the intervention in these parameters were evaluated. 209 patients were included, 97 before the intervention and 112 after the intervention. No significant differences were observed in the calculation of PSI. A significant decrease in admissions was observed after the intervention in the patients in whom the PSI was calculated (68.8% vs. 45.0%, p<0.05). A greater use of the Observation Room was aimed at those patients in whom the PSI was calculated (06.3% vs. 17.5%, p<0.05). PSI calculation significantly increased antibiotic prescription adherence (88.9% vs. 75.2%, p<0.05). There were no modifications in the prescription after the intervention. In conclusion, PSI is a useful and effective measure to achieve greater adherence to the recommendations. However, despite the positive trend in the use of the PSI and its interpretation, a low-intensity intervention is not sufficient to generalize its use.
Keywords
References
- Julián-Jiménez A, Palomo de los Reyes MJ, Parejo Miguez R, Laín-Terés N, Cuena-Boy R, Lozano-Ancín A (2013) Improved management of community-acquired pneumonia in the emergency department. Archivos de Bronconeumologia. 49 (6): 230240. doi: 10.1016/j.arbres.2012.12.0082
- Esteban-Zubero E, García-Muro C, Alatorre-Jiménez MA, Marín-Medina A, López-García CA, Youssef A, Villede-Gonzalez (2019) Management of community acquired pneumonia in the emergency room. Iberoamerican Journal of Medicine. 1 (1): 3-15. doi: 10.5281/zenodo.3402283
- Rider AC, Frazee BW (2018) Community-acquired pneumonia. Emergency Medicine Clinics of North America. 36 (4): 665683. doi: 10.1016/j.emc.2018.07.001
- Menéndez R, Torres A, Zalacaín R, Aspa J, Martín-Villasclaras JJ, Borderías L, Benítez-Moya JM, Ruiz-Manzano J, de Castro FR, Blanquer J, Pérez D, Puzo C, Sánchez-Gascón F, Gallardo J, Alvarez C, Molinos L; NEUMOFAIL Group (2005) Guidelines for the treatment of community-acquired pneumonia: predictors of adherence and outcome. American Journal of Respiratory and Critical Care Medicine. 172 (6): 757762. doi: 10.1164/rccm.200411-1444OC
- Labarere J, Stone RA, Obrosky DS, Yealy DM, Meehan TP, Fine JM, Graff LG, Fine MJ (2007) Comparison of outcomes for low-risk outpatients and inpatients with pneumonia: A propensity-adjusted analysis. Chest. 131 (2): 480-488. doi: 10.1378/chest.06-1393
- Julián-Jiménez A, González-Castillo J, Candel González FJ (2013) When, where and how should a patient with community acquired pneumonia be admitted?. Revista Clinica Espanola (Barc). 213 (2): 99107. doi: 10.1016 /j.rce.2012.02.006
- Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File Jr TM, Musher DM, Niederman MS, Torres A, Whitney CG (2007) Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clinical Infectious Diseases. 44 (2): S27-S72. doi: 10.1086/511159
- Rodríguez de Castro F (2005) The influence of specialty care on the management of hospitalized pneumonia]. Archivos de Bronconeumologia. 41 (6): 297-299. doi: 10.1016/s1579-2129(06)60228-0
- González-Moraleja J, Sesma P, González C, López ME, García JF, Alvarez-Sala JL, Cuál es el coste de las neumonías que ingresamos inadecuadamente? (1999) What is the cost of inappropriate admission of pneumonia patients?. Archivos de Bronconeumologia. 35 (7): 312-316. doi: 10.1016/s0300-2896(15)30067-3
- Ewig S, Torres A (2011) Community-acquired pneumonia as an emergency: time for an aggressive intervention to lower mortality. European Respiratory Journal. 38 (2): 253-260. doi: 10.1183/09031936.00199810
- Dean NC, Bateman KA, Donnelly SM, Silver MP, Snow GL, Hale D (2006) Improved clinical outcomes with utilization of a community-acquired pneumonia guideline. Chest. 130 (3): 794-799. doi: 10.1378/chest. 130.3.794
- Capelastegui A, España PP, Quintana JM, Gorordo I, Sañudo C, Bilbao A (2006) Evaluation of clinical practice in patients admitted with community-acquired pneumonia over a 4-year period. Archivos de Bronconeumolofia. 42 (6): 283-289. doi: 10.1016/s1579-2129(06)60144-4
- Blasi F, Iori I, Bulfoni A, Corrao S, Costantino S, Legnani D (2008) Can CAP guideline adherence improve patient outcome in internal medicine departments?. European Respiratory Journal. 32 (4): 902-910. doi: 10.1183 /09031936.00092607
- Hu WP, Zhang FY, Zhang J, Hang JQ, Zeng YY, Du CL, Jie Z-J, Jin XY, Zheng C-X, Luo X-M, Huang Y, Cheng Q-J, Qu J-M (2020) Initial diagnosis and management of adult community-acquired pneumonia: a 5-day prospective study in Shanghai. Journal Thoracic Disease. 12 (4): 1417-1426. doi: 10.21037/jtd.2020.03.02
- Delgado M, Alvarez MM, Carrascosa I, Rodríguez-Velasco M, Barrios JL, Canut A (2013) The routine use of the pneumonia severity index in the emergency department: effect on process-of-care indicators and results in community acquired pneumonia. Enfermedades Infecciosas y Microbiologia Clinica. 31 (5): 289-297. doi: 10.1016/j.eimc.2012.04.012
- Rodriguez JJ, Pastor AJ, Ferré-Llosa C, Bardés-Robles I (2014) Pneumonia severity index in the emergency department and the use of a short-stay unit to improve outcome indicators in community-acquired pneumonia. Enfermedades Infecciosas y Microbiologia Clinica. 32 (2): 132. doi: 10.1016/j.eimc.2013.07.019
- Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, Rubin HR (1999) Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA. 282 (15): 1458-1465. doi: 10.1001 /jama.282.15.1458
- Aujesky D, McCausland JB, Whittle J, Obrosky DS, Yealy DM, Fine MJ (2009) Reasons why emergency department providers do not rely on the pneumonia severity index to determine the initial site of treatment for patients with pneumonia. Clinical Infectious Diseases. 49 (10): e100-e108. doi: 10.1086/644741
- Julián-Jiménez A, Adán Valero I, Beteta López A, Cano Martín LM, Fernández Rodríguez O, Rubio Díaz R (2018) Recommendations for the care of patients with community-acquired pneumonia in the Emergency Department. Revista Espanola de Quimioterapia. 31 (2): 186-202. doi: Nil.
- Fine MJ, Auble TE, Yealy DM, Hanusa BH, Weissfeld LA, Singer DE, Coley CM, Marrie TJ, Kapoor WN (1997) A prediction rule to identify low-risk patients with community-acquired pneumonia. The New England Journal Medicine. 336 (4): 243-250. doi: 10.1056/NEJM199701233360402
- Battleman DS, Callahan M, Thaler HT (2002) Rapid antibiotic delivery and appropriate antibiotic selection reduce length of hospital stay of patients with community-acquired pneumonia: link between quality of care and resource utilization. Archives of Internal Medicine. 162 (6): 682-688. doi: 10.1001/archinte.162.6.682
- Serisier DJ, Bowler SD (2007) Effect of a simple educational intervention on the hospital management of community-acquired pneumonia. Respirology. 12 (3): 389-393. doi: 10.1111/j.1440-1843.2007.01058.x
- Halm EA, Horowitz C, Silver A, Fein A, Dlugacz YD, Hirsch B, Chassin MR (2004) Limited impact of a multicenter intervention to improve the quality and efficiency of pneumonia care. Chest. 126 (1): 100-107. doi: 10.1378/chest.126.1.100
- Yealy DM, Auble TE, Stone RA, Lave JR, Meehan TP, Graff LG, Fine JM, Obrosky DS, Mor MK, Whittle J, Fine MJ (2005) Effect of increasing the intensity of implementing pneumonia guidelines: a randomized, controlled trial. Annals of Internal Medicine. 143 (12): 881-894. doi: 10.7326/0003-4819-143-12-200512200-00006
- Blasi F, Iori I, Bulfoni A, Corrao S, Costantino S, Legnani D (2008) Can CAP guideline adherence improve patient outcome in internal medicine departments? European Respiratory Journal. 32 (4): 902-910. doi: 10.1183/ 09031936.00092607
- Renaud B, Coma E, Labarere J, Hayon J, Roy PM, Boureaux H, Moritz F, Cibien JF, Guerin T, Carre E, Lafontaine A, Bertrand MP, Santin A, Brun-Bussin C, Fine MJ, Roupie E (2007) 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. Clinical Infectious Diseases. 44 (1): 41-49. doi: 10.1086/509331
- Hinojosa Mena-Bernal J, Hinojosa Mena-Bernal C, González Sarmiento E, Almaráz Gómez A, Martín Santos S, Zapatero Gaviria A (2011) Adequacy of the admissions and care provided to the patients with community-acquired pneumonia. Revista Clinica Espanola. 211 (4): 179-186. doi: 10.1016/j.rce.2009.06.019
- Labarere J, Stone RA, Scott Obrosky D, Yealy DM, Meehan TP, Auble TE, Fine JM, Graff LG, Fine MJ (2006) Factors associated with the hospitalization of low-risk patients with community-acquired pneumonia in a cluster-randomized trial. Journal of General Internal Medicine. 21 (7): 745-752. doi: 10.1111/j.1525-1497. 2006.00510.x
- Calbo E, Ochoa de Echagüen A, Rodríguez-Carballeira M, Ferrer C, Garau J (2004) Hospital admission, duration of stay and mortality in community-acquired pneumonia in an acute care hospital. Correlation between a pneumonia prognosis index and conventional clinical criteria for assessing severity. Enfermedades Infecciosas y Microbiologia Clinica. 22 (2): 64-69. doi: 10.1016/s0213-005x(04)73036-0
- Riccioni G, Di Pietro V, Staniscia T, De Feudis L, Traisci G, Capani F, Ferrara G, Di Ilio E, Di Tano G, D'Orazio N (2005) Community acquired pneumonia in internal medicine: a one-year retrospective study based on pneumonia severity index. International Journal of Immunopathology and Pharmacology. 18 (3): 575-586. doi: 10.1177/039463200501800318
Submitted date:
11/03/2022
Reviewed date:
11/26/2022
Accepted date:
12/07/2022
Publication date:
11/08/2024