title: Association between timing of intensive care unit admission and outcomes for emergency department patients with community-acquired pneumonia.
abstract: OBJECTIVE
  To compare the 28-day mortality and hospital length of stay of patients with community-acquired pneumonia who were transferred to an intensive care unit on the same day of emergency department presentation (direct-transfer patients) with those subsequently transferred within 3 days of presentation (delayed-transfer patients).
  
  
  METHODS
  Secondary analysis of the original data from two North American and two European prospective, multicenter, cohort studies of adult patients with community-acquired pneumonia.
  
  
  METHODS
  In all, 453 non-institutionalized patients transferred within 3 days of emergency department presentation to an intensive care unit were included in the analysis. Supplementary analysis was restricted to patients without an obvious indication for immediate transfer to an intensive care unit.
  
  
  METHODS
  None.
  
  
  RESULTS
  The sample consisted of 138 delayed-transfer and 315 direct-transfer patients, among whom 150 (33.1%) were considered to have an obvious indication for immediate intensive care unit admission. After adjusting for the quintile of propensity score, delayed intensive care unit transfer was associated with an increased odds ratio for 28-day mortality (2.07; 95% confidence interval, 1.12-3.85) and a decreased odds ratio for discharge from hospital for survivors (0.53; 95% confidence interval, 0.39-0.71). In a propensity-matched analysis, delayed-transfer patients had a higher 28-day mortality rate (23.4% vs. 11.7%; p = 0.02) and a longer median hospital length of stay (13 days vs. 7 days; p < .001) than direct-transfer patients. Similar results were found after excluding the 150 patients with an obvious indication for immediate intensive care unit admission.
  
  
  CONCLUSIONS
  Our findings suggest that some patients without major criteria for severe community-acquired pneumonia, according to the recent Infectious Diseases Society of America/American Thoracic Society consensus guideline, may benefit from direct transfer to the intensive care unit. Further studies are needed to prospectively identify patients who may benefit from direct intensive care unit admission despite a lack of major severity criteria for community-acquired pneumonia based on the current guidelines.
authors.affiliation: Department of Emergency Medicine, AP-HP, Groupe Hospitalier Henri Mondor-Albert Chenevier, Créteil, France. bertrand.renaud@hmn.aphp.fr
authors.forename: Bertrand
authors.initials: B
authors.lastname: Renaud
authors.forename: Aline
authors.initials: A
authors.lastname: Santin
authors.forename: Eva
authors.initials: E
authors.lastname: Coma
authors.forename: Nicolas
authors.initials: N
authors.lastname: Camus
authors.forename: Dave
authors.initials: D
authors.lastname: Van Pelt
authors.forename: Jan
authors.initials: J
authors.lastname: Hayon
authors.forename: Merce
authors.initials: M
authors.lastname: Gurgui
authors.forename: Eric
authors.initials: E
authors.lastname: Roupie
authors.forename: Jérôme
authors.initials: J
authors.lastname: Hervé
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Fine
authors.forename: Christian
authors.initials: C
authors.lastname: Brun-Buisson
authors.forename: José
authors.initials: J
authors.lastname: Labarère
mesh_terms: D000368:Aged; D017714:Community-Acquired Infections / Q000401:mortality; D004636:Emergency Service, Hospital; D005060:Europe; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D007902:Length of Stay / Q000706:statistics & numerical data*; D016015:Logistic Models; D008297:Male; D009656:North America; D010343:Patient Admission; D010360:Patient Transfer; D011014:Pneumonia / Q000401:mortality*; D011446:Prospective Studies; D013997:Time Factors