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Emerg Med Australas. 2018 Aug;30(4):538-546. doi: 10.1111/1742-6723.12947. Epub 2018 Apr 2.

Utility of community-acquired pneumonia severity scores in guiding disposition from the emergency department: Intensive care or short-stay unit?

Author information

1
Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.
2
Burns, Trauma and Critical Care Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.
3
Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.

Abstract

OBJECTIVE:

To assess community-acquired pneumonia severity scores from two perspectives: (i) prediction of ICU admission or mortality; and (ii) utility of low scores for prediction of discharge within 48 h, potentially indicating suitability for short-stay unit admission.

METHODS:

Patients with community-acquired pneumonia were identified from a prospective database of emergency patients admitted with infection. Pneumonia severity index (PSI), CURB-65, CORB, CURXO, SMARTCOP scores and the Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) minor criteria were calculated. Diagnostic accuracy statistics (sensitivity, specificity, predictive values, likelihood ratios and area under receiver operating characteristic curves [AUROC]) were determined for both end-points.

RESULTS:

Of 618 patients admitted with community-acquired pneumonia judged eligible for invasive therapies, 75 (12.1%) were admitted to ICU or deceased at 30 days, and 87 (14.1%) were discharged within 48 h. All scores effectively stratified patients into categories of risk. For prediction of severe pneumonia, SMARTCOP, CURXO and IDSA/ATS discriminated well (AUROC 0.84-0.87). SMARTCOP and CURXO showed optimal sensitivity (85% [95% confidence interval (CI) 75-92]), while specificity was highest for CORB and CURB-65 (93% and 94%, respectively). Using lowest risk categories for prediction of discharge within 48 h, only SMARTCOP and CURXO showed specificity >80%. PSI demonstrated highest positive predictive value (31% [95% CI 24-39]) and AUROC (0.74 [95% CI 0.69-0.79]).

CONCLUSIONS:

Community-acquired pneumonia severity scores had different strengths; SMARTCOP and CURXO were sensitive with potential to rule out severe disease, while the high specificity of CORB and CURB-65 facilitated identification of patients at high risk of requirement for ICU. Low severity scores were not useful to identify patients suitable for admission to short-stay units.

KEYWORDS:

clinical decision-making; emergency medicine; pneumonia; prognosis

PMID:
29609223
DOI:
10.1111/1742-6723.12947
[Indexed for MEDLINE]

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