There are over 500,000 hospitalizations annually for patients with communityacquired pneumonia (CAP). While a great deal of attention has been paid to the diagnosis, assessment of severity, and selection and timing of antimicrobial therapy in CAP, few studies have looked at the level of clinical stability necessary for safe discharge. Pneumonia Patient Outcomes Research Team (PORT) consensus practice guidelines for the management of these patients suggest a checklist of seven vital signs that should be stabilized before hospital discharge. No studies have looked at the importance of the order in which these components of clinical stabilization occurs. We sought to assess whether there is any impact of the number, order, or sequencing of components of clinical stabilization (“vitals stabilization”) in patients hospitalized for CAP.
Data were abstracted from the inpatient charts of 1461 patients hospitalized for CAP between 2000 and 2006 across five different academic medical centers located in different US states. Detailed clinical information on the timing of stabilization of each of the seven recommended stability indicators were collected to assess adherence to Infectious Diseases Society of America/American Thoracic Society treatment and discharge guidelines (during the 24 h before discharge, the patient should have no more than one of the following characteristics: temperature >137.8°C (Temp); pulse >100 beats/min (P); respiratory rate >24 breaths/min (RR); systolic blood pressure >90 mm Hg (SBP); blood oxygen saturation <90% (O2); failure to return to baseline mental status (MS), or failure to return to baseline ability to maintain oral intake (OI)).
Mean length of stay (LOS) was 5.1 days (SD 5.1), mean number of vitals stabilized before discharge was 6.2 (SD 1.3), and median number of days to vitals stabilization was 3.5 days. Average total cost per hospitalization was $9,837. All of these varied significantly by study center. 86% had five or more vitals stabilized at discharge, but only 49% were discharged with all seven stabilized. SBP (22%) and MS (22%) were the most often criteria stabilized first, followed by OI (16%), RR (11%), Temp (11%), O2 (10%), and P (8%). The last criteria stabilized were most often O2 levels (31%), followed by P (21%), OI (15%), Temp (14%), RR (8%), MS (8%), and SBP (4%). For some persons, some vitals were recorded as being stabilized at the same time.
In this study of hospitalized community acquired pneumonia patients, we find marked differences across study centers in the length of stay, total cost, and number of indicators of clinical stability. The order in which vitals were stabilized exhibited great heterogeneity, with oxygen saturation levels and pulse rates most often not stabilized until right before discharge.
To cite this abstract:Meltzer D, Hougham G, Ruhnke G, Tak H, Ham S. Indicators of Clinical Stability in Community Acquired Pneumonia: Does the Resolution Sequence Matter?. Abstract published at Hospital Medicine 2012, April 1-4, San Diego, Calif. Abstract 97591. Journal of Hospital Medicine. 2012; 7 (suppl 2). https://www.shmabstracts.com/abstract/indicators-of-clinical-stability-in-community-acquired-pneumonia-does-the-resolution-sequence-matter/. Accessed August 25, 2019.