Pneumonia: Criteria for Patient Instability on Hospital Discharge

doi:10.1378/chest.07-3039

Chest

Volume 134, Issue 3, September 2008, Pages 595-600

https://doi.org/10.1378/chest.07-3039 Get rights and content

Background

A study was undertaken to identify and weigh at the time of hospital discharge simple clinical variables that could predict short-term outcomes in patients with pneumonia.

Methods

In a prospective observational cohort study of 870 patients discharged alive after hospitalization for pneumonia, we collected oxygenation and vital signs on discharge and assessed mortality and readmission within 30 days. From the β-parameter obtained in a multivariate Cox proportional hazard regression model, a score was assigned to each predictive variable. The effects of instability at discharge on outcomes within 30 days thereafter were examined by adjusted models with use of the pneumonia severity index at hospital admission, the length of stay, the Charlson comorbidity index, or the preillness functional status.

Results

Four variables related to a 30-day mortality rate from all causes were identified in the multivariate model; these included one major criterion (temperature >37.5°C) and three minor criteria (systolic BP < 90 mm Hg or diastolic BP < 60 mm Hg, respiratory rate > 24 breaths/min, and oxygen saturation < 90%). The developed score remained significantly associated with a higher risk-adjusted rate of death. Patients with a score ≥ 2 (one major criterion or two minor criteria) had a sixfold-greater risk-adjusted hazard ratio (HR) of death (HR, 5.8; 95% confidence interval, 2.5 to 13.1).

Conclusions

Four criteria of instability on discharge seem to be related to the mortality rate after discharge, but each of the factors must be weighed differently. The resulting score is a simple alternative that can be used by clinicians in the discharge process.

Section snippets

Setting of Study

This study was performed at Galdakao Hospital (Spain), a 400-bed, nonurban teaching general hospital serving a population of 300,000 inhabitants that provides free unrestricted care to nearly 100% of the population. The project was approved by the hospital ethics review board.

Study Sample

All patients ≥ 18 years old who were hospitalized with pneumonia consecutively between July 15, 2003, and June 30, 2006, were prospectively enrolled in an observational cohort study. Pneumonia was defined by clinician

Results

Characteristics of the study subjects are provided in Table 1. Of the 870 patients discharged alive, pneumonia-related causes accounted for 27 of the total readmissions (37.5%) within 30 days, and for 34 of the total readmissions (36.2%) within 45 days. The most frequent causes of pneumonia-related readmission within 30 days were a new rise in temperature and increased respiratory symptoms (18 patients, 66.7%) and pleural effusion (6 patients, 22.2%). Of those readmitted for pneumonia-related

Discussion

Our study showed that four easily obtainable measures of patient instability on discharge—one major criterion (temperature > 37.5°C) and three minor criteria (systolic BP < 90 mm Hg and/or diastolic BP < 60 mm Hg, respiratory rate > 24 breaths/min, and oxygen saturation < 90%)—were independently related to 30-day mortality after discharge, but with significantly different weights for each variable. At discharge, only one variable, oxygen saturation < 90%, was related to readmission for all

Acknowledgment

We thank the staff members of the different services for their support. We also wish to thank Ms. Sally Ebeling for her assistance editing the manuscript.

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Cited by (20)

Predictors and impact of time to clinical stability in community-acquired pneumococcal pneumonia
2014, Respiratory Medicine
Citation Excerpt :
CS is a useful indicator of the appropriate timing to transition from intravenous to oral antibiotics and for hospital discharge [1,2]. Moreover, the time to CS (TCS) has been shown to affect clinical outcomes after discharge [3–5]. Both CS and TCS seem to play an important role in the treatment and clinical course of CAP.
A clinical stability (CS) evaluation is thought to be important in community-acquired pneumonia (CAP) treatment, but evidence concerning the time to CS (TCS) remains lacking.
Among consecutive patients hospitalized with pneumococcal pneumonia, relationships between TCS and other clinical outcomes were examined, and predictors and a predictive TCS score were derived from patient characteristics on admission.
A total of 144 patients were enrolled, including 46% and 27% with moderate and severe pneumonia, respectively, defined by the pneumonia severity index (PSI). The median TCS was 2 days, and was significantly correlated with the length of hospital stay (r = 0.595); a longer TCS was significantly associated with the more presence of poor clinical outcomes and ICU stays (adjusted odds ratios: 1.359 and 1.366, respectively). A multivariate Cox proportional hazard model revealed an absence of bilateral pneumonia (hazard rate (HR): 2.107) or bacteremia (HR: 2.520), and mild or moderate pneumonia (HR: 2.798 and 2.515, respectively, versus severe) as predictors of CS. A predictive score had moderate discriminating power for the prolonged TCS (area under the curve: 0.76), and provided similar predictive values for poor clinical outcomes and ICU stays. A score of 3 or more points indicated the prolonged TCS, with a sensitivity and specificity of 73.3% and 70.9%, respectively.
Because TCS has a significant relationship with other clinical outcomes of pneumococcal CAP, the prediction of TCS might lead to the prevention of complications or an earlier transition to oral therapy. Future studies are warranted to validate these results.
An evaluation of clinical stability criteria to predict hospital course in community-acquired pneumonia
2013, Clinical Microbiology and Infection
Citation Excerpt :
Assessment of treatment response and thereby the concept of clinical stability, has emerged as a crucial component of CAP management and a number of methods exist that incorporate a combination of clinical and/or laboratory markers [7–9]. Assessing clinical stability can facilitate a number of essential decisions, such as intravenous to oral antibiotic switch [10], duration of antibiotic therapy [11,12], site of care within hospital settings and discharge from hospital [13,14]. Furthermore, clinical stability can potentially be used as a surrogate endpoint in clinical trials in CAP, as clinical stability is associated with favourable clinical outcomes [7,8].
A number of different methods exist to assess clinical stability, a key component of pneumonia management. We compared the prognostic value of different stability criteria through a secondary analysis of the Edinburgh pneumonia study database. We studied four clinical stability criteria (Halm's criteria, the ATS criteria, CURB and 50% or more decrease in C-reactive protein from baseline). Outcomes included 30-day mortality, need for mechanical ventilation or vasopressor support (MV/VS), development of a complicated pneumonia, and a combined outcome of the above. A total of 1079 patients (49.8% male), with a median age of 68 years (IQR 53–80), were included. Ninety-three patients (8.6%) died by day 30, 91 patients (8.4%) required MV/VS and 99 patients (9.2%) developed a complicated pneumonia. Patients with increasing severity of pneumonia on admission, assessed by both CURB-65 and PSI, took a progressively longer time to achieve clinical stability assessed by any method (p < 0.001 for all criteria). Halm's criteria had the highest area under the curve (AUC) for prediction of 30-day mortality (AUC 0.95 (0.94–0.96)), need for MV/VS (AUC 0.96 (0.95–0.97)) and combined adverse outcome (AUC 0.96 (0.95–0.97)). C-reactive protein had the highest area under the curve for complicated pneumonia (AUC 0.96 (0.95–0.97)). Adding C-reactive protein to Halm's criteria increased the area under the curve, but the difference was only statistically significant for complicated pneumonia. All of the criteria performed well in predicting adverse outcomes in patients with pneumonia. Halm's criteria performed best when identifying patients at low risk of complications.
Association between time to clinical stability and outcomes after discharge in hospitalized patients with community-acquired pneumonia
2011, Chest
Citation Excerpt :
These steps may be crucial in decreasing morbidity and mortality after discharge. In the present study, adverse outcomes (readmission and death) after discharge are similar to those published recently.4–6 Our data on readmission rate (14%) are similar to those of Jasti et al,3 who found that 12% of patients were readmitted within 30 days after initial presentation.
Adverse outcomes after discharge in patients hospitalized for community-acquired pneumonia (CAP) might be associated with the inflammatory response during hospitalization, recognized by the length of time needed for the patient to reach clinical stability (time to clinical stability [TCS]). The objective of this study was to assess the association between TCS and outcomes after discharge in hospitalized patients with CAP.
A retrospective cohort study of consecutive patients discharged alive after an episode of CAP was conducted at the Veterans Hospital of Louisville, Kentucky, between 2001 and 2006.
Among the 464 patients enrolled in the study, 82 (18%) experienced an adverse outcome within 30 days after discharge, leading to either readmission or death. Patients with a TCS > 3 days showed a significantly higher rate of adverse outcomes after discharge compared with those with a TCS ≤ 3 days (26% vs 15%, respectively; OR, 1.98; 95% CI, 1.19-3.3; P = .008) as well as adverse outcomes after discharge related to pneumonia (16% vs 4.6%, respectively; OR, 4.07; 95% CI, 2-8.2; P < .001). The propensity-adjusted analysis showed that delay in reaching TCS during hospitalization was associated with a significant increased risk of adverse outcomes. Adjusted ORs comparing patients who reached TCS at days 2, 3, 4, and 5 to those who reached TCS at day 1 were 1.06, 1.54, 2.40, and 10.53, respectively.
Patients with CAP who experienced a delay in reaching clinical stability during hospitalization are at high risk of adverse outcomes after discharge and should receive close observation and an early follow-up.
A Scoring System to Predict Readmission of Patients With Acute Pancreatitis to the Hospital Within Thirty Days of Discharge
2011, Clinical Gastroenterology and Hepatology
Reducing rapid readmission of patients after discharge could improve quality of treatment and reduce costs. Little is known about clinical predictors of early readmission for acute pancreatitis (AP). We developed a strategy to identify and stratify patients with AP at risk for readmission within 30 days of discharge.
We derived and validated a model in a cohort of patients hospitalized with AP from June 2005–October 2009. Early readmission was defined as admission to the hospital or reevaluation in the emergency department within 30 days of discharge. The cohort was divided into a derivation cohort (admitted June 2005–December 2007, n = 248) and a validation cohort (admitted January 2008–October 2009, n = 198). A weighted scoring system was developed using logistic regression for the prediction of early readmission. Accuracy was assessed by area under the receiver-operator characteristic (ROC) curve analysis.
Of the total patients, 21% (92/446) had early readmission. Multivariable analysis identified the following discharge characteristics as independent risk factors for early readmission: gastrointestinal symptoms, eating less than a solid diet, pancreatic necrosis, treatment with antibiotics, and pain (P < .05). Weighted risk scores stratified patients into groups of low, moderate, and high risk for early readmission: 4%, 15%, and 87%, respectively, in the derivation cohort and 5%, 18%, and 68%, respectively, in the validation cohort. Area under the ROC curve demonstrated an accurate prediction (c-statistic = 0.83).
We created a scoring system that accurately predicts which patients with AP have high and low risk of readmission within 30 days of discharge.
Predictors of short-term rehospitalization following discharge of patients hospitalized with community-acquired pneumonia
2009, Chest
Among patients hospitalized for community-acquired pneumonia (CAP), the risk factors for short-term hospital readmission after discharge are unknown.
We conducted a prospective observational study of 1,117 patients who had been discharged alive after hospitalization for CAP. We collected variables associated with CAP severity at hospital admission, in-hospital clinical evolution, clinical instability factors on hospital discharge, therapy employed during hospitalization, and diagnostic bacteriology. We assessed hospital readmission within 30 days after discharge for the index hospitalization. Risk factors independently associated with 30-day hospital readmission were identified using Cox regression models.
Of the 81 patients (7.3%) who were readmitted to the hospital within 30 days, 29 (35.8%) were rehospitalized for pneumonia-related causes. Variables associated with pneumonia-related hospital readmission were treatment failure (hazard ratio [HR], 2.9; 95% CI, 1.2 to 6.8), and one or more instability factors on hospital discharge (HR, 2.8; 95% CI, 1.3 to 6.2). The predictive performance of these variables measured by the area under the curve (AUC) of the receiver operating characteristic was 0.65. Variables associated with pneumonia-unrelated hospital readmission were age ≥ 65 years (HR, 4.5; 95% CI, 1.4 to 14.7), Charlson comorbidity index ≥ 2 (HR, 1.9; 95% CI, 1.0 to 3.4), and decompensated comorbidities during in-hospital evolution (HR, 3.5; 95% CI, 2.0 to 6.3); the AUC for this model was 0.77. Patients with at least two risk factors were at significantly increased risk of 30-day hospital readmission (pneumonia-related CAP: HR, 9.0; 95% CI, 3.2 to 25.3; pneumonia-unrelated CAP: HR, 5.3; 95% CI, 1.6 to 18.1).
Among patients hospitalized for CAP, different risk factors are associated with hospital readmission related to pneumonia or to other causes. The identification of two different groups of patients who were at high risk of hospital readmission raises the possibility that different management strategies could decrease the rate of hospital readmissions.
Patients' instability, emergency response, and outcomes in the radiology department
2011, American Journal of Critical Care
Citation Excerpt :
The CCI has been validated in various populations of patients15,16 and across different hospital systems internationally14-17; CCI score is a consistent predictor of 1-year mortality and in-hospital mortality. The CCI total scores for this RD-MET sample are high (50% of CCI scores ≥5) compared with CCI total scores reported in other instability studies that featured patients in general care areas (Hravnak et al,9 8.9% CI ≥4; Capelastegui et al,18 12.5% CCI ≥3; Chin et al,19 20% CCI ≥4). CCI total scores of 5 of higher have been associated with high mortality and complications related to comorbid conditions in hospitalized patients.19,20
Inpatients may be at risk of cardiopulmonary instability during radiologic testing. Calling the medical emergency team is one rescue intervention that brings a team of critical care providers to the unstable patient. Little is known, however, about patients’ instability and activations of the medical emergency team in the radiology department (RD-MET).
To describe the cause of activation of the RD-MET for hospitalized patients, temporal attributes of RD-MET involvement, characteristics of RD-MET patients, and characteristics associated with good and poor outcomes after RD-MET activation.
Retrospective pilot study of RD-MET calls for 64 inpatients in a tertiary care hospital during 2009.
Reasons for RD-MET activation were 39% neurological, 38% cardiac, and 22% respiratory, and nearly half (42%) occurred during a computed tomography scan. Most RD-MET calls were made between 10 am and noon. RD-MET patients had a mean age of 61 (SD, 19) years; 52% were female, and 89% were white. Admitting diagnoses were most commonly neurological (20%), cardiovascular (16%), and abdominal (16%). The most common comorbid conditions were chronic obstructive pulmonary disease (23%) and diabetes (20%). Half of RD-MET inpatients were from a general care unit, and 56% required preexisting oxygen support. After RD-MET involvement, 61% of patients required a higher level of care; 3% died during the MET intervention, and 19% died later in hospitalization. Patients with preexisting comorbid conditions were more likely to have poor outcomes after the RD-MET intervention (P = .001).
RD-MET patients with comorbid conditions, from a general care unit, and at risk for neurological deterioration arrive in the radiology department with potentially underestimated support needs. Greater support in specific time frames and locations may be warranted to improve outcomes.

View all citing articles on Scopus

The authors have no conflicts of interest to disclose.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

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Chest

Original ResearchInfectionPneumonia: Criteria for Patient Instability on Hospital Discharge

Background

Methods

Results

Conclusions

Section snippets

Setting of Study

Study Sample

Results

Discussion

Acknowledgment

Lancet

Chest

Arch Bronconeumol

Am J Med

A controlled trial of a critical pathway for treatment of community-acquired pneumonia

JAMA

2004 update of BTS pneumonia guidelines: what's new?

Thorax

Prospective payment system and impairment at discharge: the “quicker-and-sicker” story revisited

JAMA

What factors influence physicians' decisions to switch from intravenous to oral antibiotics for community-acquired pneumonia?

J Gen Intern Med

Time to clinical stability in patients hospitalized with community-acquired pneumonia: implications for practice guidelines

JAMA

Instability on hospital discharge and the risk of adverse outcomes in patients with pneumonia

Arch Intern Med

Adverse outcomes in patients with community acquired pneumonia discharged with clinical instability from internal medicine department

Scand J Infect Dis

Validity of composite end points in clinical trials

BMJ

A prediction rule to identify allocation of inpatient care in community-acquired pneumonia

Eur Respir J

Original Research
Infection
Pneumonia: Criteria for Patient Instability on Hospital Discharge