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

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1 Interventions to improve emergency-department management of community-acquired pneumonia ORIGINAL ARTICLE AGUSTÍN JULIÁN-JIMÉNEZ 1, RAQUEL PAREJO MIGUEZ 2, RAFAEL CUENA BOY 3, MARÍA JOSÉ PALOMO DE LOS REYES 1, NATIVIDAD LAÍN TERÉS 1, AGUSTÍN LOZANO ANCÍN 1 1 Servicio de Urgencias, Hospital Virgen de la Salud, Toledo, Spain. 2 Centro de Salud Pedro Fuente de Bargas, Toledo, Spain. 3 Farmacología Clínica, Complejo Hospitalario de Toledo, Toledo, Spain. CORRESPONDENCE: Agustín Julián Jiménez Servicio de Urgencias Hospital Virgen de la Salud Avda. Barber, Toledo, Spain agustinj@sescam.jccm.es RECEIVED: ACCEPTED: CONFLICT OF INTEREST: The authors declare no conflict of interest in relation with the present article. ACNOWLEDGEMENTS: The authors wish to thank the departments of admission, documentation and Microbiology, Complejo Hospitalario de Toledo, for help in data collection and drafting the manuscript; and all the physicians whose adherence to the guidelines made this study posible as well as improving the attention of patients with pneumonia. 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. [Emergencias 2013;25: ] Keywords: Community-acquired pneumonia. Emergency health services. Clinical practice guidelines. Biomarkers. Procalcitonin. Pneumonia Severity Index. Antibiotic. Mortality. Introduction Community-acquired pneumonia (CAP) is the leading cause of death from infectious disease in our setting (8-14% of cases) and the leading cause of severe sepsis (SS) and septic shock in the emergency department (ED) 1-3. In Spain the incidence is around 2-5 cases per 1000 inhabitants / year (15-35 cases per 1000 inhabitants / year in times of viral epidemics, patients > 65 years and in patients with chronic or toxic habits) 3-5. Of all radiologically confirmed CAP, 75% are attended in EDs at some point, which highlights the role of the emergency physician (EP) in the initial management of these processes, with impact on evolution, morbidity and mortality 1,3,6. There is great variability between centers and even colleagues in the diagnostic and therapeutic approach and management of CAP patients 7,8, but the application or implementation of clinical practice guidelines (CPG) is known to improve care, treatment and prognosis of these patients 5,9,10. EPs must rap- Emergencias 2013; 25:

2 A. Julián-Jiménez et al. idly decide when and where to admit CAP patients and what care these patients require. The adequacy or otherwise of these decisions affects the prognosis of the patient as do the lab tests and microbiological studies requested, the choice of antimicrobial regimen and the use of health resources 5,11. Along with the decision on where to place the patient, the early administration of an appropriate antimicrobial regimen and the hemodynamic measures and respiratory support necessary are the most important factors in the evolution and mortality of these patients 12,13. In our experience 5,14, and that of other authors 9,10,15,16, the implementation of a CPG is the main tool to decrease clinical variability and improve management of the infectious process. But how long does the beneficial effect of implementing a CPG last? Is it equally beneficial for all patients regardless of severity level or admission? After a preliminary study in 2008 in our ED, we found that there was great variability in practice with very poor adhesion to the recommended CPG 17. That year we published "Management of CAP in the ED" 18 prepared by a working group composed of members of SEMES (Spanish Society of Emergency Medicine) and SEPAR (Spanish Society of Pneumology and Thoracic Surgery) in order to serve as a CPG for EPs and thus reduce clinical variability and improve the comprehensive management of CAP in the ED 1. Three years later (2011) 19, that document was updated by the SEMES infections group (IN- FURG-SEMES) according to new international 12 and national recommendations 4 adapted for Spanish ED use. The aim of this study was to evaluate the impact of interventions, with implementation of CPGs referred to above (SEMES-SEPAR 2008 and INFURG-SEMES 2011), on the care process of CAP, comparing indicators (appropriate discharge or admission, early antibiotics, complementary tests) and outcomes (length of hospital stay and clinical stabilization, mortality, revisits to the ED, etc.) before and after each intervention and since the beginning in 2008 to the end of the study in Method We performed an observational, single-blind study with prospective pre- and post-intervention follow up of patients in four phases or groups (G1, G2, G3 and G4): before and after two interventions over five years, involving the implantation and / or refresher courses on the CPG "Management of CAP in the ED" (SEMES-SEPAR and INFURG-SEMES ) along with sessions for all EPs and residents of the center, as described below. The study followed the same methodology as the previous one performed with only G1 and G2. It was performed at the Hospital of Toledo, a 786-bed tertiary level center serving 437,000 people. The ED had an area for internal medicine area serviced by our own staff EPs and residents of various medical specialties. During the years it served an average visits / day and the incidence of CAP in patients > 15 was 0.62%-0.98% of all patients seen in the ED ( cases per 1000 inhabitants / year, respectively ). CAP patients could be discharged from the ED (including those who remained under observation for 24 hours), be admitted to the intensive care unit (ICU) or the short stay unit (SSU) for <72 hours, or the departments of pulmonology, internal medicine or geriatrics and, to a lesser extent, other services with specialists on call 24 hours (e.g. nephrology and oncology or hematology). EPs made the admission decision and the initial area of care, except for ICU admissions. Discharge from the ED was determined by the ED physician, referring some to the patient s primary care physician or to a specialist according to the characteristics of each patient. The study period and population was organized by two independent collaborators, experienced EPs who participated in the drafting of the CPG, without other doctors knowing this. Throughout the study they assessed the initial eligibility of ED cases from January 1, 2008 to July 31, 2012, to include 200 consecutive patients at each stage or group (G): G1 or pre-intervention from 1/1/2008 to 30/09/2008; G2 or post-intervention from 04/10/2008 to 1/8/2009 (from 02/08/2009 until patients were not included washout period after the first intervention which also coincided with the influenza A H1N1 pandemic), G3 or prior to the 2 nd intervention from 2/1/2009 to 15/9/2011, and G4 from 29/11/2011 to 31/7/2012. To be included, patients had to meet the following criteria: be aged less than 15 years and diagnosed with CAP (defined as the existence of a compatible acute symptoms including cough, dyspnea, fever, pleuritic chest pain, altered level of consciousness etc., and its radiological demonstration of new lung infiltrates) in the ED by the physician responsible. Immunocompromised patients were excluded (infection by human immunodeficiency virus, solid viscera transhospital ward, splenectomy, treated with 10 mg or more of prednisone daily or equiv- 380 Emergencias 2013; 25:

3 INTERVENTIONS TO IMPROVE EMERGENCY-DEPARTMENT MANAGEMENT OF COMMUNITY-ACQUIRED PNEUMONIA alent for more than 30 days, or treated with other immunosuppressive agents) and patients hospitalized in the previous 14 days. The two collaborators also assessed final eligibility, removing patients who at 30 days did not meet the criteria for a final diagnosis of CAP (codes 481, 482, 483, 485, 486 and 507 of the International Classification of Diseases 9th revision clinical Modification: ICD-9CM), and who received a final diagnosis of tuberculosis, cases of viral etiology, flu, fungal infection or lung abscess (corresponding to codes 480, 487, 484 and 513 of the ICD-9CM). Also excluded were patients diagnosed with a second episode of CAP during the entire period. The study met the ethical standards of our hospital and was approved by the Clinical Research Ethics Committee. The monitoring of all patients was performed through computerized ED and PC medical records, with telephone consultation with the patient or family (subject to consent) or PC doctor on occasions. Study interventions consisted of CPG implementation and evaluation of adherence. Between 1-3 October 2008 (1 st intervention) and November 2011 (2 nd intervention) the CPG were distributed, both complete 1,3 and in pamphlet format 18,19, and training sessions were held for all EPs and residents. Both times the physicians were requested to consistently apply all the CPG recommendations. Furthermore, in the second intervention we showed them the results of the first and how the management of CAP had improved in our ED. Also, and specifically, we included training on the usefulness of both the systematic application of the Pneumonia Severity Index (PSI) 16 and other criteria11 which included biomarkers 20,21. The two independent collaborators, unknown to the rest of the doctors, were responsible for applying the criteria for evaluation of patients. To evaluate and analyze the performance of doctors in each case "proper management" was defined as agreement with each of the measures and treatments as recommended in the CPG, and "mismanagement " if not. This assessment was performed independently for the request for complementary studies from the ED (laboratory and microbiological tests, and biomarkers), for the prognostic assessment and decision on destination according to the modified PSI 11 (additional criteria) and to the choice and administration of treatment in the ED. We excluded cases in which there was a discrepancy between the two raters. CAP was defined as severe and needing ICU assessment when patients fulfilled one major or three minor criteria established by ATS / IDSA (American Thoracic Society Infectious Diseases Society of America) To assess the severity and prognosis of patients with CAP and the decision on admission we used the PSI, whose risk groups were created according to those proposed by the original authors 22 to which various additional criteria were included (Table 1 ) (also explained and transmitted in all training sessions) according to the recommendations by SEMES-SEPAR 2008 and INFURG- SEMES Thus, all patients belonging to risk groups PSI IV- V and those belonging to PSI risk groups I- III with any of the risk factors or criteria in Table 1 were considered as those requiring hospital admission. We collected all the socio-demographic, clinical, exploratory, analytical and radiological variables included in PSI 22, in the 2007 ATS/IDSA 12 criteria for ICU admission and in the criteria for the definition of sepsis, SS and Septic shock according to the expert conference We calculated the PSI value and grade, the original Charlson 24 index weighted for age and the presence of sepsis, SS, Septic shock and severe CAP. The following variables were added: previous antimicrobial treatment (within 72 hours before ED visit), physician profile (resident, emergency physician, other specialists), presence of diabetes or chronic obstructive pulmonary disease (COPD ), the number of comorbidities (including those contained in the PSI plus diabetes and COPD), the lab tests indicated by the CPG (including in each case blood count, coagulation, biochemistry and blood gases), appropriate microbiological tests (blood, urine antigen assays, sputum), pulse oximetry (O 2 saturation), C reactive protein (CRP) and procalcitonin (PCT), the administration and time (within 4 hours) of an antibiotic, the choice of antibiotic and appropriate dosage, change in antibiotic regimen in patients admitted within 48 hours or in the home dosage for patients discharged home within 72 hours after discharge, the overall treatment duration and any adverse effects and complications. Finally, as outcome measures, we included: ED revisits and readmission within 30 days, clinical stabilization times (according to the criteria of Halm and Teirstein 25 ) and hospital stay, microbiological diagnosis when available, the patient's initial destination (discharge, observation, SSU, hospital ward or ICU). Re-assessment within hours of discharged patients, clinical and radiological status at 3-6 weeks and mortality in discharged patients, hospitalized patients or those admitted to the ICU, and overall mortality at 30 days. Emergencias 2013; 25:

4 A. Julián-Jiménez et al. Table 1. Additional criteria and risk factors that condition the decision to admit or discharge patients according to recommendations of the clinical practice guidelines used Respiratory failure with PaO 2 < 60 mmhg or O 2 saturation by pulse oximetry < 90%. Evidence of existing comorbidity of the decompensated ED patient. Existence of pleural effusion (encapsulated or > 2 cm on chest x-ray in lateral decubitus position). Radiological multilobular involvement ( 2 lobes ipsilateral or bilateral involvement). CAP with criteria of severe sepsis or septic shock. Great probability or suspicion of bacteremia due to clinical situation and/or biomarkers (CRP 90 mg/ml and/or Procalcitonin > 1 ng/ml). Existence of situations or factors that impede correct treatment. Such as oral intolerance, social problems (dependent patient without available caregiver, psychiatric disorders, alcohol abuse, etc.). Failure to respond to previous antibiotic treatment (72h after initiating adequate antibiotic therapy before clinical or radiological deterioration). PaO 2 : partial arterial pressure of oxygen; ED: Emergency Department; CAP: community acquired pneumonia; CRP: C-reactive protein. Adapted from reference 5. In the statistical analysis we used means and standard deviations (SD), ranges, medians and percentages, as appropriate, to describe the demographic, clinical, evolution and treatment of patients in the four phases. In addition, to estimate population values, 95% confidence intervals (CI) of averages and percentages were calculated. Comparisons between groups (G1-G4) were performed using ANOVA with Tukey post hoc analysis and, where appropriate, equality of means (Welch test), Student's t test, Mann Whitney U test, chi-square and Fisher 's exact test, depending on both the number of groups to be compared (two or more) and the type of measurement of the variable (scale, ordinal or nominal). In order to control for possible confounders, we used an unconditional logistic regression model. As dependent variables we used in-hospital mortality and mortality at 30 days, and as independent variables we used the phase or group (G1- G4), age, number of comorbidities, the Charlson index, the PSI group and coexistence of sepsis, SS and Septic shock (variables that could influence mortality and heterogeneously distributed between phases). Thus, we calculated the odds ratio (OR) for mortality and phase with their 95% CI. With the same purpose of controlling for confounders, we also used a multiple linear regression model to determine whether the possible association between overall duration of antibiotic and intravenous therapy and group (G1-G4) remained after controlling for patient destination (discharge, observation, SSU, hospital ward or ICU) and PSI risk group. The estimation and comparison between groups (G1-G4) to the end of admission (hospital stay) and the time until clinical stabilization were done using Kaplan Meier method and log-rank test. Also, using a Cox proportional hazards model (with Schoenfeld study of residuals to compare their applicability), we estimated hazard ratios (HR) of these results (end of admission and medical stabilization) for the groups G2-G4 versus G1, adjusted for PSI group and destination of the patient. Statistical analysis was performed with IBM SPSS Statistics 19 for Windows and differences with a p value of < 0.05 were considered statistically significant. Results 200 patients were included in each of the 4 groups (G1-G4) after excluding, respectively, 52, 37, 42 and 29 cases with no diagnosis of CAP during follow up according to the defined codes. Similarly, we excluded 5, 3, 3 and 6 patients in whom there was disagreement between the evaluators on performance in the ED. There were no significant differences in the profile of the physician in the ED (emergency physician / resident / other specialists) between the 4 groups with ratios of % vs % vs % vs %, respectively, p = Table 2 shows the socio-demographic, clinical and severity characteristics, comorbidities, Charlson index (original and weighted), and distribution of all study patients as classified by the PSI. There were no differences between groups for most variables except for the variable taking antibiotics within 72 hours, a greater proportion of nursing home patients with COPD, increased Charlson index and PSI and more patients with SS criteria in group G4. There were no significant differences between groups in relation to radiological presentation (multilobar and / or bilateral CAP and pleural effusion) or laboratory or blood gas parameters (Table 3), except for a greater proportion of patients with PaO 2 less than 60 mmhg in the G4 and G3 versus G2 and G1 (p = 0.010) and a greater proportion of renal failure and hyponatremia in G4. Final microbiological confirmation of the diagnosis did show significant differences between G1 and G2 versus G3 and G4 (12%, 15%, 40.5% and 38.5%, respectively, p < ), but not in the distribution of pathogens (p = 0.12) (Table 4). As reflected in Table 3, there were significant differences between G1-G4 in ED request for CRP and / or PCT ( 19. 3%, 90%, 40% and 93.5%, respectively, p < 0.001). However, and 382 Emergencias 2013; 25:

5 INTERVENTIONS TO IMPROVE EMERGENCY-DEPARTMENT MANAGEMENT OF COMMUNITY-ACQUIRED PNEUMONIA Table 2. Socio-demographic and clinical characteristics of patients treated in the Emergency Department (ED) for communityacquired pneumonia (CAP) Characteristics of patients Group 1 Group 2 Group 3 Group 4 P-value P-value (n = 800) n = 200 n = 200 n = 200 n = 200 Intergroup 1 Groups 1 and 4 2 n (%) n (%) n (%) n (%) Demographic data Age (years) [mean (SD)] 56 (22) 58 (22) 55 (21) 59 (21) Median (range) 58 (18-99) 60 (18-99) 56 (15-98) 60 (19-98) Male sex 118 (59%) 122 (61%) 125 (62.5%) 130 (65%) Origin of residence 19 (9.5%) 20 (10%) 25 (12.5%) 34 (17%) AB taken within 72 hours 47 (23.5%) 65 (32.5%) 75 (37.5%) 84 (42%) < Comorbidities Blood cancer 13 (6.5%) 12 (6%) 17 (8.5%) 14 (7%) Liver disease 6 (3%) 11 (5.5%) 6 (3%) 12 (5.5%) Congestive heart disease 26 (13%) 29 (14.5%) 31 (15.5%) 33 (16.5%) Cerebrovascular disease 17 (8.5%) 14 (7%) 17 (8.5%) 15 (7.5%) Chronic kidney disease 14 (7%) 14 (7%) 15 (7.5%) 17 (8.5%) Diabetes 27 (13.5%) 33 (16.5%) 34 (17%) 39 (19.5%) COPD 30 (15%) 38 (19%) 39 (19.5%) 47 (23.5%) Number Comorbidities [mean (SD)]* 0.68 (0.80) 0.77 (0.83) 0.81 (0.85) 0.91 (0.91) Median (range) 1 (0-4) 1 (0-4) 1 (0-4) 1 (0-5) Charlson index [mean (SD)] 1.29 (1.41) 1.31 (1.31) 1.59 (1.49) 1.63 (1.44) Median (range) 1 (0-6) 1 (0-6) 1 (0-7) 1 (0-7) Charlson index weighted [mean (SD)]* 2.90 (2.73) 3.05 (2.66) 3.21 (2.81) 3.42 (2.77) Median (range) 2 (0-10) 3 (0-10) 3 (0-10) 3 (0-11) Clinical and severity data Confusion-alteration of consciousness 22 (11.2%) 28 (14.07%) 26 (13.1%) 30 (15%) Hypothermia (temperature < 35 ºC) 14 (7.10%) 14 (7%) 18 (9.1%) 18 (9.1%) Criteria for sepsis 129 (64.5%) 138 (69%) 134 (67%) 146 (73%) Criteria for severe sepsis 29 (14.5%) 43 (21.5%) 39 (19.5%) 46 (23%) Criteria for septic shock 8 (4.12%) 11 (5.52%) 10 (5%) 12 (6%) Utilización ventilación mecánica invasiva o no invasiva 14 (7.21%) 22 (11%) 19 (9.5%) 24 (12%) SCAP* 43 (21.5%) 48 (24%) 52 (26%) 57 (28%) PSI PSI (years) value [mean (SD)] 93 (46) 101 (51) 97 (45) 108 (48) Median (range) 85 (17-230) 92.5 (10-268) 90 (17-231) (13-268) Distribution by PSI group PSI I 36 (18%) 38 (19%) 25 (12.5%) 22 (11%) PSI II 40 (20%) 26 (13%) 48 (24%) 27 (13.5%) PSI III 33 (16.5%) 34 (17%) 30 (15%) 41 (20.5%) PSI IV 52 (26%) 43 (21.5%) 50 (25%) 52 (26%) PSI V 39 (19.5%) 59 (29.5%) 47 (23.5%) 58 (29%) The percentages exclude the lost data if any. SD: standard deviation; AB: antibiotic; COPD: chronic obstructive pulmonary disease; PSI: Pneumonia Severity Index; NS: not significant or without sufficient sample. Group 1: Pre-protocol; Group 2: post-protocol group; Group 3: Pre-protocol of the 2nd intervention; Group 4: Post-protocol of the 2nd intervention. * Includes: neoplasia, liver disease, congestive heart disease, cerebrovascular disease, kidney disease, diabetes and COPD. *Charlson Index weighted by age (add a point to the Charlson index value for each decade starting at age 50). *SCAP: severe community-acquired pneumonia (defined in the text). 1Qualitative variables comparison by Chi square and ANOVA with post-hoc Tukey correction or non-parametric tests as appropriate for the comparison of means. 2 2 X 2 comparison of groups 1 and 4 by chi squared or Fisher exact test as appropriate. perhaps because of their greater use in G2 and G4, the levels of CRP and PCT were lower in these groups with respect to G1 with p < in both cases. Table 3 also shows greater magnitude of both markers in PSI groups III. On comparing CRP means, significant differences were found between subgroups of patients according to clinical severity criteria (p < 0.001). Similarly, on comparing PCT means, significant differences were found (p < 0.001) between patients with and without sepsis, SS, Septic shock and severe CAP. Significant differences in CRP and CPT levels were also found between patients who died within 30 days and those who survived (Table 5). Moreover, in all study patients we confirmed the existence of a significant relationship (p < 0.001) between request for biomarker tests and early administration (< 4 hours) of antibiotics in the ED (81.6% vs 67.8%), with the choice of an appropriate antibiotic regimen (87.8% vs 65.6% ), with the right choice of patient destination (87.5% vs 71.2%), with the request for appropriate lab tests (92% vs 66.6%) and the request for the appropriate microbiological studies (86.8% vs 61.4%), reflecting compliance and adherence to all CPG. In relation to antimicrobial administration and the guidelines (Table 6), there was a clear difference between groups ( G1- G4) in all cases (p < 0.001) and large proportional differences in Emergencias 2013; 25:

6 A. Julián-Jiménez et al. Table 3. Radiological and gasometric characteristics and laboratory findings in patients with community-acquired pneumonia (CAP) treated in the Emergency Department (ED) Patient characteristics (n = 800) Group 1 Group 2 Group 3 Group 4 P-value P-value n = 200 n = 200 n = 200 n = 200 Intergroup 1 Groups 1 and 4 2 n (%) n (%) n (%) n (%) Radiological and gasometric data Infiltrate Unilobar 141 (70.5%) 145 (72.5%) 129 (64.5%) 134 (67%) Multilobar 44 (22%) 42 (21%) 56 (28%) 48 (24%) Bilateral 15 (7.5%) 13 (6.5%) 15 (7.5%) 18 (9%) Pleural effusion 35 (17.5%) 37 (18.5%) 36 (18%) 49 (24%) Arterial ph < (11.5%) 25 (12.5%) 28 (14%) 33 (16.5%) PO 2 /FiO 2 < (13.80%) 34 (17.5%) 32 (17%) 39 (19.9%) PO 2 < 60 mmhg 75 (37.5%) 82 (41%) 88 (44%) 91 (45.5%) Laboratory findings Urea > 64 mg/dl or Cr >1.5 mg/dl 45 (23.43%) 55 (27.63%) 60 (30.6%) 68 (34.2%) Sodium < 130 meq/l 15 (7.81%) 22 (11.2%) 22 (11.2%) 31 (15.6%) Blood glucose > 250 mg/dl 22 (11.45%) 26 (13.06%) 28 (14.3%) 29 (14.6%) Hematocrit < 30% 20 (10.41%) 16 (8.04%) 25 (12.7%) 22 (11.1%) Leukocytosis > /mm (59.37%) 132 (66.33%) 116 (58.9%) 133 (66.3%) Leucopenia < 4.000/mm 3 28 (14.58%) 21 (10.55%) 34 (17.3%) 27 (13.6%) Thrombocytopenia < /mm 3 27 (14.06%) 28 (14.07%) 33 (16.8%) 29 (14.6%) Biomarkers Requested in the ED 38 (19.3%) 180 (90%) 80 (40%) 187 (93.5%) < < CRP (mg/l) levels [mean (SD)] (all patients) (18.72) (22.01) (25.96) (26.99) CRP (mg/l) ± SD en PSI I (24.58) (22.05) (19.26) CRP (mg/l) ± SD en PSI II (31.34) (18.51) (26.14) (22.99) CRP (mg/l) ± SD en PSI III (19.69) (16.06) (36.10) (19.94) CRP (mg/l) ± SD en PSI IV (14.64) (18.28) (27.08) (22.16) CRP (mg/l) ± SD en PSI V (15.06) (20.11) (27.44) (25.13) PCT (ng/ml) levels [mean (SD)] 4.89 (11.31) 2.51 (12.88) 2.81 (9.56) 2.87 (10.28) PCT (ng/ml) ± SD en PSI I 0.60 (0.32) 1.34 (1.15) 0.76 (0.83) PCT (ng/ml) ± SD en PSI II 3.31 (4.47) 1.22 (1.47) 1.55 (1.71) 0.83 (0.56) PCT (ng/ml) ± SD en PSI III 3.63 (2.82) 1.31 (1.47) 1.09 (0.87) 1.05 (1.32) < PCT (ng/ml) ± SD en PSI IV 3.79 (4.00) 1.56 (1.31) 2.75 (2.03) 1.48 (1.78) PCT (ng/ml) ± SD en PSI V 4.56 (3.65) 5.16 (4.92) 4.78 (6.32) 5.45 (12.92) Group 1: Pre-protocol; Group 2: post-protocol group; Group 3: Pre-protocol of the 2nd intervention; Group 4: Post-protocol of the 2nd intervention. 1 Qualitative variables compared by Chi squared or Fisher exact test and ANOVA with post-hoc Tukey correction or non-parametric tests as appropriate for the comparison of means. 2 2 X 2 comparison of groups 1 and 4 by chi squared or Fisher exact test as appropriate. the variables that can change and influence the development, evolution and prognosis of patients with CAP. Antibiotic administration in the ED, early administration, the appropriate choice and dosage, and early antibiotic administration with fluid therapy in cases of SS and Septic shock in the ED were greater in G2 and G4. Conversely, patients whose antibiotic regimen was initially changed was significantly lower in groups G2 and G4. The duration of total antibiotic treatment in Table 4. Confirmed microbiological diagnoses Total Group 1 Group 2 Group 3 Group 4 N = 800 n = 200 n = 200 n = 200 n = 200 n (%) n (%) n (%) n (%) n (%) Not identified 588 (73.5%) 176 (88%) 119 (59.5%) 170 (85%) 123 (61.5%) Streptococcus pneumoniae 123 (15.3%) 11 (5.5%) 48 (24%) 18 (9%) 46 (21%) Legionella pneumophila 20 (2.5%) 3 (1.5%) 7 (3.5%) 4 (2%) 6 (3%) Mycoplasma pneumoniae 21 (2.62%) 3 (1.5%) 7 (3.5%) 3 (1.5%) 8 (4%) Chamydophila pneumoniae 13 (1.62%) 2 (1%) 5 (2.5%) 2 (1%) 4 (2%) Haemophilus influenzae 8 (1.0%) 2 (1%) 3 (1.5%) 1 (0.5%) 2 (1%) Moraxella catarrhalis 2 (0.25%) 0 (0%) 1 (0.5%) 0 (0%) 1 (0.5%) Pseudomonas aeruginosa 11 (1.37%) 2 (1%) 4 (2%) 1 (0.5%) 4 (2%) Staphylococcus aureus 3 (0.37%) 0 (0%) 2 (1%) 0 (0%) 1 (0.5%) Klebsiella pneumoniae 2 (0.25%) 0 (0%) 1 (0.5%) 0 (0%) 1 (0.5%) Gram-negative bacilli 9 (1.12%) 1 (0.5%) 3 (1.5%) 1 (0.5%) 4 (2%) The diagnosis was made by isolation of the pathogen in blood cultures, sputum culture, antigenuria or by serology when the first test was requested in the ED and seroconversion during follow-up (a comprehensive diagnostic protocol was not defined in all patients for serology extraction, which was carried out on the basis of clinical and/or epidemiologic suspicion in each case). Group 1: Pre-protocol; Group 2: post-protocol group; Group 3: Preprotocol of the 2nd intervention; Group 4: Post-protocol of the 2nd intervention. 384 Emergencias 2013; 25:

7 INTERVENTIONS TO IMPROVE EMERGENCY-DEPARTMENT MANAGEMENT OF COMMUNITY-ACQUIRED PNEUMONIA Table 5. Relationship between levels of biomarkers and clinical severity and mortality CRP (mg/l) PCT (ng/ml) Mean (SD) P-value Mean (SD) P-value Criteria for severe CAP p < p < Yes (23.5) 7.99 (10.1) No (22.9) 1.42 (1.9) Criteria for sepsis p < p = Yes (24.2) 5.16 (11.4) No (23.8) 1.62 (2.9) Severe sepsis p < p < Yes (25.6) (17.3) No (22.8) 1.73 (2.5) Septic shock p < p < Yes (34.9) (22.5) No (23.4) 2.77 (6.9) Mortality in the ICU p < p < Yes (27.6) (25.0) No (25.1) (18.7) In-hospital mortality p = p < Yes (15.5) 8.83 (7.7) No (21.4) 2.34 (2.6) Global mortality at 30 days p = p < Yes (20.1) (18.1) No (25.4) 2.97 (7.7) CRP: C-reactive protein: PCT: Procalcitonin; SD: standard deviation; CAP: community-acquired pneumonia; ICU: intensive care unit. hospitalized patients was higher in G1 and G3, both globally [G1: 11.8 (3.8), G2: 10.4 (3.3) G3: 11.8 (3.7), G4: 9.6 (3.1) days, p < 0.001] as in each of the groups based on PSI (Table 6). The same occurred with the duration of intravenous antibiotic therapy in all patients [G1: 6.8 (4.5), G2: 5.8 (3.0), G3: 7.1 (4.6), G4: 4.8 (2.5) days, p < 0.001] and the PSI subgroups (Table 6). After adjusting for group (G1-G4), patient destination (discharge, observation, SSU, hospital ward or ICU) and group according to PSI, mean differences remained significant, so that the coefficient for G2 versus G1 for total time of antibiotic use [ 1.56 days on average (95% CI 2.63 to 0.50), p = 0.004] and time of intravenous antibiotic use [ 1.37 days (95% CI 2.15 to 0.55), p = remained different. And also for G4 compared to G1 for the total time of antibiotic use [ 2.66 days (95% CI: 3.70 to 1.63), p < 0.001] and intravenous antibiotic time [ 2.25 days (95% CI: 3.03 to 1.47), p < 0.001]. As for decisions regarding specific care action (Table 7), there were significant differences in favor of G2 and G4 as to analytical and microbiological studies (blood, urinary antigen, sputum culture). There was also a greater number of changes in decisions (antimicrobials or destination of the patient) after interpreting biomarkers in G2 and G4 (G1: 10.8%, G2: 26.1%, G3: 10.7%, G4: 29.6%, P = 0.007). Finally, it is striking that O 2 saturation was not reflected in 12.5% of G1 and 11.5% of G3 patients compared to 2% in G2 and 1% in G4 (p < 0.001); and these differences were more pronounced in the PSI I subgroup. Direct discharge from the ED was higher in G1 and G3, while for G2 and G4 in most cases it was decided to leave the patient under observation and there was a higher percentage of ICU admissions from the ED (Table 8). 35.5% of patients in G1 and 34.5% of G3 had an inappropriate initial destination (incorrect discharge or admission) versus 3.5% of G2 and 2% of G4 (p < 0.001) according to PSI recommendations and the additional criteria listed in Table 1. In particular, "incorrect discharge" decreased in the PSI group IV-V from 25.5% (G1) and 28.9% (G3) to 2% (G2) and 1% (G4) (p < 0.001) and inadequate admission or discharge in PSI groups I-III decreased from 44% (G1) and 39.8% (G3) to 5.1% (G3) and 3.4% (G4) (p < 0.001). On the other hand, both patient follow up hours after discharge and clinical and radiological at 3-6 weeks was significantly higher in G2 and G4 (p < 0.001), while the number of ED revisits in the first 72 hours and 30 days and the rate of readmissions among these was lower in G2 and G4, with significant differences (Table 8). Regarding hospital stay times and achieving clinical stabilization (Halm and Teirstein criteria 25 ) results are listed in Table 8. Median time to clinical stabilization in patients admitted to the observation area, SSU and hospital ward was significantly higher in G1 and G3 than in G2 and G4. After adjusting for PSI group and location this result was sustained for G2 with a HR of (95% CI: , p < 0.001) and for G4 with a HR of (95% CI: to 2.504, p < 0.001), the reference group being G1. There were also differences between groups (G1-G4) in the length of hospital stay (G1: 8.7 ± 5.5, G2: 7.6 ± 4.0, G3: 9.4 ± 6.0 and G4: 6.5 ± 4.0 days, p = 0.001). After adjusting for PSI group and destination of the patient (discharge, observation, SSU, hospital ward or ICU) using G1 as the reference group, differences remained (p < 0.001) for both G2 [HR (95% CI: to 2.351)] and G4 [HR of (95% CI: )]. Figure 1 shows comparative hospital stay times. Table 9 shows the results related to mortality. No significant differences were found between groups (G1-G4) in patients discharged or admitted to the ICU. But there were differences in hospital mortality (G1 20%, G2 6.6%, G3 15.6% and G4 4.3%, p = 0.001) and overall mortality at 30 days (G1 15%, G2 8.5%, G3 11.5% and G4 Emergencias 2013; 25:

8 A. Julián-Jiménez et al. Table 6. Related factors and indicators of antibiotic management of patients with community-acquired pneumonia (CAP) Group 1 Group 2 Group 3 Group 4 P-value P-value n = 200 n = 200 n = 200 n = 200 Intergroup 1 Groups 1 and 4 2 n (%) n (%) n (%) n (%) Confirmed administration of AB a 151 (76.3%) 196 (99.0%) 162 (81.4%) 200 (100%) < < Early AB b (within 4 hours) 85 (44.7%) 171 (89.1%) 93 (47%) 184 (92.5%) < < Adequate choice of AB b 119 (60.4%) 190 (95.5%) 123 (61.8%) 195 (97.5%) < < Correct doses and routes a 112 (57.1%) 190 (95.5%) 117 (59.1%) 194 (97.5%) < < Change of AB treatment in patients admitted* 59 (49.6%) 14 (10.5%) 68 (51.1%) 10 (6.9%) < < Change of AB treatment in patients discharged home** 25 (34.7%) 3 (4.5%) 26 (38.2%) 0 (0%) < < Early AB, fluid therapy and request for lactate in patients with severe sepsis or septic shock 10 (31.2%) 48 (92.3%) 24 (49%) 60 (98.4%) < < Side effects attributed to the AB*** 18 (6.1%) 6 (3.0%) 17 (8.6%) 6 (3.03) ED revisit attributed or due to AB side effects 11 (14.9%) 3 (5%) 9 (12.9%) 3 (4.8%) AB treatment (days) [mean (SD)] (3.8) (3.3) (3.7) 9.59 (3.1) < < PSI I (2.1) 7.45 (1.5) (1.8) 6.86 (1.6) < < PSI II (2.0) 8.77 (2.3) (2.4) 7.11 (1.6) < < PSI III (2.2) 9.85 (2.2) (2.7) 8.49 (2.0) < < PSI IV (4.3) (2.6) (4.2) (2.7) PSI V (5.6) (3.8) (4.8) (3.2) Days of intravenous AB in admitted [mean (SD)] 6.76 (4.5) 5.76 (3.0) 7.12 (4.6) 4.80 (2.5) < < PSI III 4.16 (1.9) 3.62 (1.9) 4.20 (2.8) 2.84 (1.7) PSI IV 7.57 (3.9) 5.40 (2.5) 7.22 (3.8) 4.71 (2.2) < < PSI V 9.08 (5.0) 7.30 (2.9) 9.66 (4.9) 6.29 (2.1) < The percentages exclude missing data; AB: antibiotic; ED: Emergency Department; iv: intravenous; Group 1: Pre-protocol; Group 2: post-protocol group; Group 3: Pre-protocol of the 2nd intervention; Group 4: Post-protocol of the 2nd intervention. *Includes any change of type of antimicrobial and/or your dosage within 48 hours of admission to the short stay unit, hospital ward or intensive care unit. This difference is more relevant (p < 0.05) in PSI groups IV and V between groups 1 vs 2, 1 vs 4 and 3 vs 4. **Includes any change of type of antimicrobial and dosage within 72 hours by the primary care physician, ED or outpatient clinic in directly or ED observation discharged patients. This difference is relevant (p < 0.05) in the PSI I groups between groups 1 and 2, 1 and 4, and 3 and 4. ***Includes those in the 30 days after ED diagnosis attributed to the AB (vomiting. diarrhea. intolerance. hepatotoxicity or nephrotoxicity or allergic reactions). b there were also differences (p < 0.05) between subgroups according to degrees of PSI between the groups 1 versus 2-4 and 3 versus 4. b There were also differences (p < 0.05) between subgroups according to degrees of PSI and clinical severity grades (patients with sepsis. severe sepsis and septic shock) between groups 1 and 2-4 and 3 versus 4. 1 Qualitative variables comparison by Chi square and ANOVA and post-hoc Tukey correction or non-parametric tests as appropriate for the comparison of means. 2 2 x 2 comparison of groups 1 and 4 by chi squared or exact Fisher test as appropriate. 5.5%, p = 0.012). These differences were greater on comparing G1 to G4. The results based on PSI group are also reflected in Table 9. In addition, incorrect versus correct choice of antibiotic in the ED was associated with hospital mortality and overall mortality at 30 days (both p < 0.001). Moreover, early administration of antibiotics in the ED was associated with lower hospital mortality (p < 0.001) and overall mortality at 30 days (p = 0.003) (data and percentages are shown in Table 10). Finally, a comparison between groups (G1-G4) controlling for related covariates (age, number of comorbidities, Charlson index, PSI group and existence of sepsis, SS or Septic shock) the differences remained significant for G2, with p = and OR: (95% CI: ) and G4, with p < and OR: (95% CI: to 0.269). And similarly for overall mortality at 30 days adjusted for the same covariates, differences were also found for G2, with p = and OR: (95% CI: ) and G4, with p < and OR: (95% CI: to 0.331). Discussion The implementation of a CPG for CAP in an ED, including biomarkers of inflammation and infection 20,21, the PSI 16 as a prognostic scale and different additional criteria for assessing severity 11 and admission/discharge decision has proved to be an effective tool for reducing the variability of important decisions taken by emergency physicians (ordering analytical and microbiological studies, early administration of appropriate therapy and appropriate destination) 5. It has also improved overall mortality, decreased the rate of inappropriate discharge and admission, reduced the time required to achieve stabilization and hospital stay time 5,9,10. But, how long is this beneficial effect maintained after implementation of the CPG? Is it equally useful for all patients regardless of severity and treatment site? In any case, after the implementation of a CPG, one should evaluate both the overall impact of each variable and indicator, to identify areas for improvement and to confirm achievement of the objectives. 386 Emergencias 2013; 25:

9 INTERVENTIONS TO IMPROVE EMERGENCY-DEPARTMENT MANAGEMENT OF COMMUNITY-ACQUIRED PNEUMONIA Table 7. Factors relating to the appropriateness of emergency department (ED) care of patients with community-acquired pneumonia (CAP) ED care variables (n = 800) Group 1 Group 2 Group 3 Group 4 P-value P-value n = 200 n = 200 n = 200 n = 200 Intergroup 1 Groups 1 and 4 2 n (%) n (%) n (%) n (%) Non-performance of pulse oximetry in ED 25 (12.5%) 4 (2%) 23 (11.5%) 1 (0.5%) < < Change of decision in ED after interpreting biomarker values when requested a 4 (10.8 %) 41 (26.1%) 6 (10.7%) 48 (29.6%) Correct request for lab tests 130 (65.6%) 184 (92%) 148 (74%) 191 (95.5%) < < Correct request for microbiological tests 117 (58.5%) 183 (91.5%) 125 (62.5%) 190 (95%) < < Request for blood cultures 98 (49.5%) 157 (78.5%) 117 (58.5%) 173 (86.5%) < < Request for antigenuria* 94 (47.5%) 155 (77.5%) 113 (56.5%) 175 (87.5%) < < Request for sputum culture 20 (10.1%) 36 (18%) 20 (10%) 40 (20%) Microbiological diagnosis obtained** 24 (12%) 81 (40.5%) 30 (15%) 77 (38.5%) < < The percentages exclude missing data; ED: Emergency Department; Group 1: Pre-protocol; Group 2: post-protocol group; Group 3: Pre-protocol of the 2nd intervention; Group 4: Post-protocol of the 2nd intervention. *Request for pneumococcal antigen and if negative and/or epidemiologic suspicion, then Legionella. **Sputum culture, blood culture, antigenuria after final serological diagnosis if requested in the ED first sample. aconsidered when this fact was reflected in the clinical history. 1 Qualitative variables comparison by Chi square and ANOVA and post-hoc Tukey correction or non-parametric tests as appropriate for the comparison of means. 2 2 X 2 comparison of groups 1 and 4 by chi squared or exact Fisher test as appropriate. We can say that every intervention was effective for the patient and efficient for the system: all the indicators showed significant positive change between G1 and G2 and between G3 and G4, or between G1 and G4, or at least with a certain magnitude of effects, reinforcing previously published findings 5,14. Our results are very similar to those of Capelastegui et al. 9 who, after implementing a Table 8. Factors and indicators of the evolution and destination of patients diagnosed with community-acquired pneumonia (CAP) Group 1 Group 2 Group 3 Group 4 P-value P-value n = 200 n = 200 n = 200 n = 200 Intergroup 1 Groups 1 and 4 2 n (%) n (%) n (%) n (%) Destination of the patient from ED Discharge 73 (36.5%) 39 (19.5%) 54 (27%) 36 (18%) < < Observation and discharge 18 (9%) 32 (16%) 18 (9%) 27 (13.5%) SSU 24 (12%) 27 (13.5%) 28 (14%) 28 (14%) Hospital ward 73 (36.5%) 75 (37.5%) 86 (43%) 77 (38.5%) ICU 12 (6%) 24 (12%) 14 (7%) 26 (13%) Deaths in the ED 0 (0%) 3 (1.5%) 0 (0%) 2 (1%) Correct destination according to PSI and additional criteria* 129 (64.5%) 190 (96.5%) 131 (65.5%) 195 (98%) < < Correct decision in PSI IV-V 68 (74.4%) 97 (98%) 69 (71.1%) 108 (99%) < < Correct decision in PSI I-III 61 (56%) 93 (94.9%) 62 (60.2%) 87 (96.6%) < < ED revisit within hours 39 (69.6%) 63 (95.5%) 41 (63.1) 57 (95%) < < ED revisit within 3-6 weeks 87 (62.6%) 164 (91.6%) 115 (69.7%) 173 (92.5%) < < ED revisit within 72 hours after the initial discharge 13 (14.28%) 2 (2.81%) 10 (13.88%) 1 (1.58%) < ED revisit within 30 days after discharge, motivated by CAP 22 (28.57%) 3 (4.5%) 20 (22%) 2 (3.2%) < Admission after ED revisit by the patient 13 (63.6%) 2 (66.7%) 12 (60%) 0 (0%) Hospital stay in days [mean (SD)] 8.73 (5.5) 7.59 (4.0) 9.39 (6.0) 6.48 (4.0) < PSI I 1.60 (0.9) 1.50 (0.7) 5.67 (2.9) 3.67 (3.8) PSI II 3.10 (2.3) 4.60 (3.3) 5.05 (3.3) 2.50 (1.6) PSI III 6.15 (2.9) 4.62 (2.3) 6.55 (5.9) 3.41 (2.0) PSI IV (4.8) 7.57 (3.6) 9.80 (5.1) 6.37 (3.1) < < PSI V (6.1) 9.46 (3.8) (6.4) 8.83 (4.1) Stabilization in days [mean (SD)]** 3.45 (1.4) 3.08 (1.4) 3.72 (1.7) 2.91 (1.3) < PSI I 2.40 (1.0) 1.94 ( (0.8) 1.82 (0.7) < PSI II 2.64 (1.0) 2.28 (0.9) 2.98 (1.1) 2.11 (0.6) PSI III 3.24 (0.9) 2.50 (0.8) 3.17 (0.9) 2.12 (0.6) < < PSI IV 4.31 (1.3) 3.48 (1.1) 4.08 (1.1) 3.22 (1.0) < < PSI V 4.92 (1.0) 4.61 (1.4) 5.45 (2.5) 4.21 (1.4) The percentages exclude missing data; CAP: community-acquired pneumonia; AB: antibiotic; ED: Emergency Department; OR: odds ratio; CI: confidence interval; NS: not significant. *In addition to PSI group and additional criteria (Table 1), the clinical assessment or argument made by the doctor. **According to the criteria of Halm et al (reference 25): heart rate < 100 bpm, respiratory frequency < 24 bpm, temperature < 37.2 C, systolic blood pressure > 90 mmhg. O 2 saturation > 90%, good level of consciousness and oral tolerance. Group 1: Pre-protocol; Group 2: post-protocol group; Group 3: Pre-protocol of the 2nd intervention; Group 4: Post-protocol of the 2nd intervention. 1 Qualitative variables compared by Chi square and ANOVA and post-hoc Tukey correction or non-parametric tests as appropriate for the comparison of means. 2 2 X 2 comparison of groups 1 and 4 by chi squared or exact Fisher test as appropriate. Emergencias 2013; 25:

10 A. Julián-Jiménez et al. CPG in their hospital, achieved a reduction of antibiotic treatment times (global 1.5 days and intravenous 1.3 days), hospital stay (1.8 days) and inadequate antibiotic regimen (from 28.6% to 11.8%). These authors also reported a reduction in hospital mortality (OR 2.46, 95% CI: 1.37 to 4.41) and overall mortality at 30 days (OR 2.14, 95% CI: ). However, two fundamental differences exist between the Capelastegui study and ours. They had an external control group from other centers and only included hospitalized patients. Blasi et al. 10 also focused on hospitalized patients, and their results are similar to ours. Physician adherence to their CPG on the management of CAP was very low (33%), as in our case before the first (25%) and second (40%) intervention in our ED, but the effectiveness was evident with reduced mortality (OR 0.77, 95% CI: 0.51 to 0.98) and increased appropriate choice of antibiotic, identified as one of the most important factors related to mortality reduction (9.1% to 5.7%), as in our study (shown in Table 9) where the choice of an incorrect antibiotic in the ED was associated with both in-hospital and overall 30-day mortality. Early administration of antibiotics in the ED was also associated with lower in-hospital and 30- Beds occupied (cumulative proportion) Group 1 Group 2 Group 3 Group 4 P < 0, Days from admission Figure 1. Distribution of discharges and beds occupied. Kaplan-Meier survival curves showing the proportion of beds occupied (stay) by patients in each study group. day mortality. In a study of 780 hospitalized patients with CAP, Dambrada et al. 26 confirmed differences in mortality according to CPG-recom- Table 9. Mortality of patients with community-acquired pneumonia (CAP) after being treated in the emergency department (ED) Mortality (n = 800) Group 1 Group 2 Group 3 Group 4 P-value P-value n = 200 n = 200 n = 200 n = 200 Intergroup 1 Groups 1 2 n (%) n (%) n (%) n (%) and 4 Mortality in patients discharged after initial visit to the ED 1 of 87 (1.1%) 0 of 71 (0%) 0 of 69 (0%) 0 of 62 (0%) In-hospital mortality 20 of 100 (20%) 7 of 106 (6.60%) 19 of 122 (15.6%) 5 of 117 (4.3%) < in hospital ward or SSU according to PSI group: PSI I 0 (0%) 0 (0%) 0 (0%) 0 (0%) NS NS PSI II 1 (10%) 0 (0%) 2 (10.5%) 1 (12.5%) NS NS PSI III 0 (0%) 0 (0%) 0 (0%) 0 (0%) NS NS PSI IV 5 (12.8%) 1 (2.6%) 4 (10.8%) 1 (2.2%) NS NS PSI V 14 (45.2%) 6 (14.6%) 13 (31.7%) 3 (7.5%) In-hospital mortality in those admitted to the ICU 5 of 13 (38.5%) 6 of 24 (25%) 2 of 15 (13.3%) 5 of 29 (17.2%) According to PSI group: PSI I 0 (0%) 0 (0%) 0 (0%) 0 (0%) NS NS PSI II 0 (0%) 0 (0%) 0 (0%) 0 (0%) NS NS PSI III 0 (0%) 0 (0%) 0 (0%) 0 (0%) NS NS PSI IV 2 (28.6%) 0 (0%) 1 (14.3%) 0 (0%) NS NS PSI V 3 (60%) 6 (33.3%) 1 (12.5%) 5 (22.7%) NS NS Mortality at 30 days considering all patients 30 of 200 (15%) 17 of 200 (8.5%) 23 of 200 (11.5%) 5 of 200 (5.5%) According to PSI group: PSI I 0 (0%) 0 (0%) 0 (0%) 0 (0%) NS NS PSI II 1 (2.5%) 0 (0%) 2 (4.2%) 1 (3.7%) NS NS PSI III 0 (0%) 0 (0%) 0 (0%) 0 (0%) NS NS PSI IV 9 (17.3%) 1 (2.3%) 6 (12%) 1 (1.9%) PSI V 20 (51.3%) 16 (27.1%) 16 (34%) 10 (17.2%) PSI: Pneumonia Severity Index; NS: not significant or excessively low sample size; Group 1: Pre-protocol; Group 2: post-protocol group; Group 3: Preprotocol of the 2nd intervention; Group 4: Post-protocol of the 2nd intervention. 1 Qualitative variables compared by Chi square and ANOVA and posthoc Tukey correction or non-parametric tests as appropriate for the comparison of means. 2 2 X 2 comparison of groups 1 and 4 by chi squared or exact Fisher test as appropriate. 388 Emergencias 2013; 25:

11 INTERVENTIONS TO IMPROVE EMERGENCY-DEPARTMENT MANAGEMENT OF COMMUNITY-ACQUIRED PNEUMONIA Table 10. Relationship between mortality and administration of antibiotic therapy In-hospital Mortality 30-day Mortality Yes No p Yes No p AB administration in the ED No 10.8% 89.2% 8.1% 91.9% Yes 11.6% 88.4% 10.4% 89.6% Early* AB administration < No 21.3% 78.7% 15% 85% Yes 7.5% 92.5% 7.9% 92.1% Appropriate dosage of AB < < No 34.5% 65% 22.6% 77.4% Yes 5.9% 94.1% 6.9% 93.1% AB: antibiotic; ED: emergency room. *Early: during the first four hours of ED stay. mended antibiotic adherence or not (3% vs 10.6%). These differences are comparable to those that we observed (5.5% vs. 15%). We believe these results reflect the importance of early and appropriate antibiotics for the prognosis of CAP as outlined in the CPGs 1,4,18,19. Even when only some physicians adhere to CPG recommendations, as Dean et al. 15 showed with their 10% rate of adherence, one can achieve a decrease in mortality (OR 0.92, 95% CI: 0.87 to 0.98, p = 0.007). Hence the importance of periodic interventions and training since the benefits of CPG application decrease with the passage of time. Along with the systematic use of PSI and additional criteria, the inclusion of biomarkers (PCR and PCT) as complementary to the prognostic severity scales (PSI and / or CURB- 65) 11 or as predictors of bacteriemia 27 and mortality 28 is increasingly common in the ED. Therefore, as previously described, in our study, PCT value > 1 ng / ml was included as an additional criterion for admission to hospital (or at least observation), as well as blood cultures and early antibiotic therapy due to the likelihood of bacteremia and / or progression to SS or septic shock, as recommended by various authors 11,20,27. The present study confirmed that high concentrations of biomarkers (especially PCT) were associated with bacteremia, and mortality. Therefore, and in accordance other authors 11,20,27 we would recommend that CAP patients with PCT > ng / ml require blood cultures and early antibiotic therapy, and use this as an additional criterion in prognostic evaluation with PSI. The decision to admit or discharge the patient determines the prognosis and evolution. Routine use in the ED of CPG that incorporate a PSI results in a decrease of incorrect hospitalization, better placement (ambulatory or hospital) and adequacy of early antibiotic therapy 16,29. The variability in rate of hospitalization between different medical centers is great when CPG are not followed. Aujesky et al. 30 in a study conducted in 12 EDs with high physician adherence to CPG with PSI found that 37.4% of patients with PSI I- III were admitted and 3.2% with PSI IV-V were discharged home. In another recent study, Hinojosa et al. 31 assessed the appropriateness of hospital admissions for CAP and found a lower proportion of inappropriate admissions (6.1%) in the low-risk group (PSI I-III), but a large proportion of inappropriate discharges (according to the PSI and additional criteria) which reached 32.9%. In our study, inappropriate admissions significantly decreased in G2 and G4 (from 35.5% to 3.5% and from 34.5 to 2%, p < 0.001), but, as in the work by Hinojosa31, incorrect discharge was observed in low-risk patients (PSI I-III) rather than inappropriate admission. We believe that the improvement in admission/discharge decision in our study was due to several factors: direct discharge from the ED was higher in G1 and G2 versus G3 and G4 (36.5% and 19.5% vs. 27% and 18%, p<0.001 ); G2 and G4 patients were referred to ED observation more often than G1 and G3 (16% and 13.5% vs 9% and 9%, p = 0.032), and a PCT > 1 ng / ml was the criterion that changed the decision from discharge to admission in 28% of PSI I-III patients (assuming a high inflammatory response and / or probability of bacteremia). In addition to greater effectiveness for the patient, the introduction of the CPG also resulted in greater efficiency for the system, since there were fewer unnecessary admissions, hospital stay was reduced, as was antibiotic treatment time (from 2.25 days from G1 to G4). Another aspect was the reduction of clinical stabilization time (0.54 days), which as we have seen was related to early administration of antibiotic therapy in the ED and faster release of hospital beds. Although this work reflects the change in CAP management and improved overall care in our ED, after each intervention and from the beginning (2008) to the end of the study (2012), certain limitations should be addressed. It was a single-center study, without an external comparison group, and for certain comparisons the sample size was small, e.g. comparisons between subgroups according to PSI or clinical severity (sepsis, SS and septic shock). The physicians responsible for the four groups were not the same (there was an estimated 80% turnover of emergency physicians and residents between the four periods) so a bias may exist according to experience and CPG adherence. Although quantified, the causes of in- Emergencias 2013; 25: