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You may overlook these pneumonia symptoms
72% of misdiagnoses occur in ED
Smoking, lung diseases, and chest X-ray abnormalities may result in your ED patient being diagnosed with bronchitis, flu, pleurisy, costochondritis, and upper respiratory infection, when he or she actually has pneumonia, says Carrie April, RN, BSN, an ED nurse at St. John's Mercy Medical Center in St. Louis, MO.
"Patients can be discharged from the hospital with these diagnoses, allowing the pneumonia to increase in severity," says April.
It is especially important to note all patients with a productive cough of discolored phlegm, fever, shaking, and chills, says April. Elderly and/or immune-compromised patients are at high risk for getting pneumonia, she warns.
"If misdiagnosed or undiagnosed, this population can become septic," she says. "Sepsis is a serious, life-threatening illness that will require critical care from a team of multi-disciplinary professionals."
Of 127 patients diagnosed with pneumonia at Henry Ford Hospital in Detroit between December 2008 and December 2009, and readmitted within 30 days of a previous hospitalization, 92 were misdiagnosed with health care-associated pneumonia. Of this group, 72% of the misdiagnoses occurred in the ED (see reference #1).
Hiren Pokharna, MD, MPH, the study's lead author and an infectious disease physician at Henry Ford, says that ED nurses should have a high clinical suspicion for pneumonia.
Be aware of the Centers for Disease Control and Prevention/National Healthcare Safety Network surveillance criteria for pneumonia, advises Pokharna. (see reference #2) "That way, whenever a patient presents, you can determine more closely if the patient fulfills criteria for pneumonia," he says.
Be aware of the conditions associated with misdiagnosis, adds Pokharna. "Another sub-study that we conducted suggests that most of the cases misdiagnosed as pneumonia were chronic obstructive pulmonary disorder exacerbation, congestive heart failure exacerbation, or tracheobronchitis," he says.
April recommends advocating for appropriate diagnostic tests in the ED, and using triage protocols to speed care. If a chest X-ray is ordered by the ED nurse, the radiologists can confirm a diagnosis, and antibiotics can be started immediately, she explains. "Advocate for the patient, should you feel that there is a misdiagnosis," she adds.
Ask your patient if he or she has been recently discharged from the hospital. "Hospitalized patients are at high risk for developing nosocomial infections, such as pneumonia," says April. (See related story on assessment of pneumonia, and clinical tip on chest X-rays, below.)
For more information on caring for pneumonia patients in the ED, contact:
Carrie April, RN, BSN, Emergency Department, St. John's Mercy Medical Center, St. Louis, MO. Phone: (314) 251-6090. Fax: (314) 251-7622. E-mail: firstname.lastname@example.org.
Suzanne Watson, RN, Emergency Department, Nebraska Medical Center, Omaha. Phone: (800) 922-0000. E-mail: email@example.com.
Identify pneumonia patient's true status
If your pneumonia patient is misdiagnosed, he or she could become a lot sicker and possibly need an extended hospital stay, warns Suzanne Watson, RN, ED manager at the Nebraska Medical Center in Omaha. "Unfortunately, there are still patients who die from pneumonia each year," she adds.
Carefully assess your patient's status, advises Watson, including temperature, lung sounds, oxygen saturations, signs of increased work of breathing, and retractions.
An inadequate patient history can lead to a misdiagnosis, says Watson. "Listen to what your patient is telling you, both verbally and visually," she says. "Do a complete set of vital signs, including a temperature."
Find out the length of the illness, any impact on the patient's ability to perform daily activities, and the temperature, color, and moistness of the patient's skin, says Watson. "Those are all cues to the severity of the patient's illness," she says.
Ask your patient if he or she took any antipyretics, adds Watson. "They may be afebrile in the ED because they just took [acetaminophen] or [ibuprofen] at home," she says. "Listen to lung sounds, and get an oxygen saturation. Look for retractions and any signs of cyanosis."
Admitted patients who are diagnosed with community-acquired pneumonia have a decreased mortality rate if the appropriate antibiotics are given within six hours of presentation and blood cultures are obtained prior to the antibiotic therapy, notes Watson.
"This is part of the core measure for treatment of pneumonia, which was established as best practice by the Centers for Medicare and Medicaid Services," says Watson. "This is something we track."
Don't be fooled by normal chest X-ray
Pneumonia may be misdiagnosed in your ED patient because the chest X-ray comes back essentially normal, says Suzanne Watson, RN, ED manager at the Nebraska Medical Center in Omaha.
A chest CT may be done if the ED physician is working the patient up for possible pulmonary embolism, or has a high clinical suspicion that the patient has pneumonia, she explains. "There have been times that the pneumonia is diagnosed via the chest CT, but the chest X-ray was read as normal," reports Watson.