Implementation of Admission Decision Support for Community-Acquired Pneumonia

• Published in: Chest Vol. 117; no. 5; pp. 1368 - 1377
• Main Authors: Dean, Nathan C., Suchyta, Mary R., Bateman, Kim A., Aronsky, Dominik, Hadlock, Carol J.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.05.2000; American College of Chest Physicians
• Subjects: Adult; Aged; clinical protocols; Community-Acquired Infections - diagnosis; Community-Acquired Infections - therapy; Comorbidity; Decision Support Techniques; Female; Humans; Hypoxia - diagnosis; Hypoxia - therapy; Male; Middle Aged; Patient Admission; Pilot Projects; pneumonia; Pneumonia, Bacterial - diagnosis; Pneumonia, Bacterial - therapy; practice guidelines; Practice Guidelines as Topic; Prospective Studies; Risk Factors; severity of illness index; therapy; ICD-9; pneumonia; PORT; practice guidelines; severity of illness index; therapy; PSI; clinical protocols; patient admission
• ISSN: 0012-3692; 1931-3543
• DOI: 10.1378/chest.117.5.1368

Considerable variation exists in hospital admission rates for patients with community-acquired pneumonia. Logic to determine need for admission has been proposed by several authors. We compared Intermountain Health Care pneumonia guideline recommendations for inpatient vs outpatient care with actual physician decision making and clinical outcomes before vs after implementation. A secondary objective was to determine whether the pneumonia severity index predicts need for admission in this population. Prospective study after implementation vs historic controls. Four ambulatory, urgent-care facilities. Four hundred sixty-three immunocompetent adults with radiographically confirmed community-acquired pneumonia. A pneumonia practice guideline including decision support logic was implemented for a 12-month period. After implementation, physicians used the pneumonia guideline form in 90% of cases. The percentage of patients admitted within 30 days decreased from 13.6% to 6.4% (p = 0.01). Only five patients before (2.5%) and three patients after (1.1%, p = 0.3) guideline implementation required subsequent hospital admission within 30 days after initial outpatient treatment. Only two deaths occurred in the study cohort, both outpatients before implementation. The positive predictive value was 14.4%, and the negative predictive value for admission was 98.8% after guideline implementation. Guideline recommendation for admission was more likely to be followed in patients with more risk factors and hypoxemia. Decreased admission rate was observed after implementation of admission decision support in combination with specific recommendations for outpatient antibiotic therapy. Favorable outpatient outcomes suggest that implementation of decision support was safe.