Clinical Decisionmaking

Use of intensive care for patients with severe pneumonia is common and expensive, but hospital ICU admission rates vary

Patients with community-acquired pneumonia (CAP) who are admitted to the intensive care unit (ICU) tend to be sicker, have poorer outcomes, and use more medical resources than CAP patients treated on regular hospital floors. Although use of intensive care for patients with severe pneumonia is common, hospital ICUs vary in their ICU admission rates. Also, no current diagnostic criteria adequately predict which CAP patients need ICU care, according to a study that was supported in part by the Agency for Healthcare Research and Quality (HS06468, Patient Outcomes Research Team [PORT] on Community-Acquired Pneumonia).

The researchers prospectively compared the characteristics, course, and outcomes of 170 patients who were admitted to the ICU and 1,169 patients who did not receive ICU care during a hospital stay at one Canadian and four U.S. medical centers. Overall, 13 percent of CAP patients were admitted to the ICU, with ICU admission rates ranging from 9 to 26 percent.

Reasons for ICU admission included respiratory failure (57 percent), need to monitor blood circulation (32 percent), and shock (16 percent). ICU patients had longer hospital stays (23 vs. 9 days), higher hospital costs ($21,144 vs. $5,785), more nonpulmonary organ dysfunction, and higher hospital mortality (18 vs. 5 percent) than non-ICU patients.

However, there were no differences in the total number or severity of symptoms between the two groups. In addition, although ICU patients were sicker, 27 percent were considered to be at low risk of dying. Four clinical prediction rules for severe CAP (original and revised American Thoracic Society criteria, the British Thoracic Society criteria, and the Pneumonia Severity Index) were not good predictors of subsequent care decisions (ICU admission and mechanical ventilation) and outcomes (medical complications and death). Three-quarters of the patients who met any of the criteria were never admitted to the ICU. The researchers conclude that clinical prediction rules for severe CAP are not robust enough to guide clinical care at the current time.

See "Severe community-acquired pneumonia," by Derek C. Angus, M.D., M.P.H., Thomas J. Marrie, M.D., D. Scott Obrosky M.S., and others, in the September 2002 American Journal of Respiratory and Critical Care Medicine 166, pp. 717-723.

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