Ambulatory Care Quarterly: Pneumonia guidelines will affect 750,000 ED patients

Recommendations address antibiotics, lab, SARS

An adult patient with fever and cough: This is something you probably see at least once a day and perhaps dozens of times a day in your emergency department (ED) during the flu season. But did you know about new recommendations that call for changes concerning when patients receive antibiotics, which diagnostic tests they are given, and whether they are discharged or admitted?

Newly updated guidelines for community-acquired pneumonia from the Alexandria, VA-based Infectious Diseases Society of America (IDSA) will have a major impact on the 1 million patients admitted for pneumonia each year, 75% of which are admitted through the ED.1 (For information on how to access the guidelines, see "Pneumonia Resources" at the end of this article.)

"In our hospital, 90% of all adult admitted pneumonia cases come through the ED," says Rosemary Kucewicz, RN, BSN, ED manager at Northwest Community Hospital in Arlington Heights, IL.

Approximately 30 adult pneumonia patients come to the ED each month at Harborview Medical Center in Seattle, and that number increases to 40 or 50 per month between December and March, reports Darlene Matsuoka, RN, BSN, CEN, CCRN, clinical nurse educator for the ED.

To significantly improve care of pneumonia patients and comply with updated guidelines, make the following practice changes:

Customize use of antibiotics.

Different antibiotics now are ordered for individual populations and circumstances, Matsuoka says. "By using the IDSA guidelines for pathogen-specific therapy and empiric therapy, the best antibiotic choices can be used for every patient."

The new guidelines recommend different antibiotics be used for healthy patients as opposed to those with comorbidities such as renal failure or aspiration pneumonia, Matsuoka says.

"We treat our patients with empiric antibiotics targeted to the specific site, treated as outpatient, in the nursing home, or admitted to the hospital, either to an intensive care unit or a regular nursing unit," says Nina M. Fielden, MSN, RN, CEN, an ED clinical nurse specialist at Cleveland Clinic Foundation. "Our hospital does not use fluoroquinolones unless necessary because of the concern for resistance to these drugs in our region."

The Pneumonia Outcomes Research Team Severity Index criteria are used to determine where patients should receive their treatment, she adds.

Order different tests for specific agents.

Conventional tests such as blood cultures, sputum gram stain, and sputum culture and sensitivity testing are ordered for infectious agents such as Streptococcus pneumoniae, whereas a polymerase chain reaction assay would be ordered for chlamydophilia pneumoniae or severe acute respiratory syndrome (SARS), says Matsuoka.

"Specific testing may be done for the Legionella species," she adds.

Start antibiotics within four hours of arrival for pneumonia patients who are going to be admitted.

The previous time frame called for antibiotics to be given within eight hours, so the new recommendation means quicker X-rays and laboratory testing will be needed, with earlier medical decision making about how best to treat the patient, says Matsuoka.

Average time to start antibiotics is just over three hours at Cleveland Clinic’s ED, reports Fielden. "You should get the antibiotics started as soon as possible, not waiting for them to reach the inpatient unit where it may take up to eight hours to get them started," she says.

If you suspect that the patient won’t take his antibiotics when he goes home because he is noncompliant or lacks financial resources to obtain the drug, admitting him for observation for fewer than 24 hours is a good way to get two doses of intravenous (IV) azithromycin in, adds Fielden.

"A patient with pneumonia who we want to have 24 hours of IV antibiotics gets his first IV administration in the ED and the second one 24 hours later in the clinical decision unit [CDU], and then goes home," she explains. "He may only be in the CDU 20 hours, as the time in the ED is not counted."

The Ohio ED treats approximately 50 patients a month for pneumonia, with about 12 admitted to the observation unit and 54% admitted to the hospital, Fielden reports.

Assess whether patients can be discharged home safely.

Consider the patient’s ability to take medications and care of him or herself, says Matsuoka. A patient should have no more than one of the following characteristics to be discharged, according to the guidelines:

  • temperature > 37.8°C;
  • pulse > 100 beats per minute;
  • respiratory rate > 24;
  • systolic blood pressure < 90;
  • oxygen saturation < 90%;
  • unable to maintain intake by mouth.

According to the new standards, two factors determine whether the patient is admitted: The patient’s ability for self-care at home, and whether the patient meets the above discharge criteria. For example, Matsuoka points to a wheelchair-bound pneumonia patient who lived alone with a caregiver, with problems eating and drinking due to poor muscle coordination from a previous stroke.

"The patient was febrile, tachycardic, and hypoxic, so he was admitted," she says.

Offer patients the pneumonia vaccine.

At Cleveland Clinic’s ED, nurses offer the pneumonia vaccine and influenza vaccines to anyone who presents with pneumonia and is discharged home, Fielden says.

"You usually associate it with influenza season, especially this one with the increase in pneumonia and mortality," she adds. "However, you should offer the pneumonia vaccine year round, since patients get pneumonia any time of the year."

Screen all adult pneumonia patients for SARS.

The guidelines ask you to maintain a high level of suspicion for SARS when you see adult patients with pneumonia.

"Pneumonia isn’t what it used to be," says Kucewicz.

"Ten years ago, pneumonia was pneumonia. Now it could be SARS or anthrax," she adds.

It is likely that numerous other suspected cases will be reported over the coming weeks, predicts Kucewicz. "If SARS spreads, it could present a worldwide crisis. No one sees this as going away soon."

She points to newly updated SARS guidelines from the Centers for Disease Control and Prevention (CDC), which ask you to identify patients who require hospitalization for radiographically confirmed pneumonia or acute respiratory distress syndrome without identifiable etiology, and who have one of the following risk factors in the 10 days before the onset of illness:

  • travel to mainland China, Hong Kong, or Taiwan, or close contact with an ill person with a history of recent travel to one of these areas;
  • employment in an occupation associated with a risk of SARS exposure;
  • part of a cluster of cases of atypical pneumonia without an alternative diagnosis.2

"The numbers of pneumonia cases you are seeing need to be a trigger much more so than ever before," says Kucewicz. "Be very alert to how many cases you are seeing, because you need to be able to connect the dots."

The ED will likely be the first place that a SARS outbreak is detected, adds Kucewicz. "If there is a change in what’s going on in the community, we will be the first to identify that change."

You also should be alert for clusters of pneumonia among two or more health care workers who work in the same facility, she says.

When a pneumonia patient is being admitted from the ED, the charge nurse screens with the new CDC guidelines before placing the call for the bed, reports Kucewicz.

"She stamps the ED nursing notes with a red-inked stamp that says SARS screening negative,’" she says. "The bed placement nurse also checks up on us by asking, What is the SARS screening?’ To date, all of our SARS screening has been negative."

Symptoms of SARS mimic those of several other respiratory diseases, including many that are more frequent during the winter, notes Kucewicz. "Some of these diseases may give rise to pneumonia," she says.

References

1. Mandell LA, Bartlett JG, Dowell SF, et al. Update of practice guidelines for the management of community-acquired pneumonia in immunocompetent adults clinical infectious diseases. Clin Infect Dis 2003; 37:1,405-1,433.

2. Centers for Disease Control and Prevention. Clinical Guidance on the Identification and Evaluation of Possible SARS-CoV Disease among Persons Presenting with Community-Acquired Illness, Version 2. Atlanta; Jan. 8, 2004.

Pneumonia Resources

  • The Infectious Diseases Society of America has published updated guidelines for treatment of adult patients with community-acquired pneumonia, including tables listing preferred treatment options and detailed management strategies. The guidelines can be accessed free at www.journals.uchicago.edu/IDSA/guidelines. Scroll down to "Update of Practice Guidelines for the Management of Community-Acquired Pneumonia in Immunocompetent Adults" and click on "Full text."
  • The American College of Emergency Physicians (ACEP) has a clinical policy for adult pneumonia patients in the ED. The clinical policy can be accessed free at the ACEP web site (www.acep.org). Under "Quick Links," click on "Clinical Policies," "Clinical Policy for the Management and Risk Stratification of Community-Acquired Pneumonia in Adults in the Emergency Department."