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Interventions to improve emergency-department management of community-acquired pneumonia

Julián Jiménez A, Parejo Miguez R, Cuena Boy R, Palomo De Los Reyes MJ, Laín Terés N, Lozano Ancín A

Servicio de Urgencias, Hospital Virgen de la Salud, Toledo, Spain. Centro de Salud Pedro Fuente de Bargas, Toledo, Spain. Farmacología Clínica, Complejo Hospitalario de Toledo, Toledo, Spain.

Objectives: To determine the impact of emergency-department interventions based on
clinical practice guidelines for treating community-acquired pneumonia by analyzing
and comparing management decisions (discharge vs admission; adequacy and timing of
antibiotic treatment; additional tests ordered), results over time (until patient’s condition
stabilized, duration of hospital stay, emergency department revisits), and mortality
(before and after interventions and up to 5 years).
Methods: Prospective, pre and postintervention study of cases between January 1,
2008, and July 31, 2012, in 4 phases (2 periods before introduction of interventions and
2 periods afterwards).
Results: In the patient groups just after introduction of the guidelines-based
interventions and at the end of the study, time until the patient was stabilized decreased
(by 0.54 days, P<.001), and hospital stay was shorter (by 2.25 days, P<.001). Mortality
also fell: in-hospital mortality decreased from 20% to 4.3% (P<.001), and 30-day
mortality decreased from 15% to 5.5%, P=.003). Early, adequate use of antibiotics
increased, and the total time on antibiotics decreased (by 2.25 days); time on
intravenous antibiotics also decreased (by 1.96 days) (all comparisons, P<.001). The
pneumonia severity index (PSI) and biomarkers were helpful for making decisions to
admit or discharge patients (P<.001).
Conclusion: After implementation of clinical practice guidelines and use of the PSI, the
emergency care of patients with community-acquired pneumonia improved.

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