Risk stratification of early admission to the intensive care unit of patients with no major criteria of severe community-acquired pneumonia: development of an international prediction rule.
BACKGROUND
To identify risk factors for early (< three days) intensive care unit (ICU) admission of patients hospitalised with community-acquired pneumonia (CAP) and not requiring immediate ICU admission, and to stratify the risk of ICU admission on days 1 to 3.


METHODS
Using the original data from four North American and European prospective multicentre cohort studies of patients with CAP, we derived and validated a prediction rule for ICU admission on days 1 to 3 of emergency department (ED) presentation, for patients presenting with no obvious reason for immediate ICU admission (not requiring immediate respiratory or circulatory support).


RESULTS
A total of 6560 patients were included (4593 and 1967 in the derivation and validation cohort, respectively), 303 (4.6%) of whom were admitted to an ICU on days 1 to 3. The Risk of Early Admission to ICU index (REA-ICU index) comprised 11 criteria independently associated with ICU admission: male gender, age younger than 80 years, comorbid conditions, respiratory rate of 30 breaths/minute or higher, heart rate of 125 beats/minute or higher, multilobar infiltrate or pleural effusion, white blood cell count less than 3 or 20 G/L or above, hypoxaemia (oxygen saturation < 90% or arterial partial pressure of oxygen (PaO2) < 60 mmHg), blood urea nitrogen of 11 mmol/L or higher, pH less than 7.35 and sodium less than 130 mEq/L. The REA-ICU index stratified patients into four risk classes with a risk of ICU admission on days 1 to 3 ranging from 0.7 to 31%. The area under the curve was 0.81 (95% confidence interval (CI) = 0.78 to 0.83) in the overall population.


CONCLUSIONS
The REA-ICU index accurately stratifies the risk of ICU admission on days 1 to 3 for patients presenting to the ED with CAP and no obvious indication for immediate ICU admission and therefore may assist orientation decisions.
Renaud
Bertrand
B
Department of Emergency Medicine, AP-HP, Groupe Hospitalier Henri Mondor-Albert Chenevier, Créteil, F-94010, France. bertrand.renaud@hmn.aphp.fr
Labarère
José
J
Coma
Eva
E
Santin
Aline
A
Hayon
Jan
J
Gurgui
Mercé
M
Camus
Nicolas
N
Roupie
Eric
E
Hémery
François
F
Hervé
Jérôme
J
Salloum
Mirna
M
Fine
Michael J
MJ
Brun-Buisson
Christian
C
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017714:Community-Acquired Infections / Q000503:physiopathology*; D004636:Emergency Service, Hospital; D005060:Europe; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D038622:Internationality; D008297:Male; D008875:Middle Aged; D015337:Multicenter Studies as Topic; D009656:North America; D010343:Patient Admission; D011014:Pneumonia / Q000503:physiopathology*; D011237:Predictive Value of Tests; D000091402:Prohibitins; D011446:Prospective Studies; D018570:Risk Assessment / Q000592:standards