Relationships among initial hospital triage, disease progression and mortality in community-acquired pneumonia.
OBJECTIVE
Appropriate triage of patients with community-acquired pneumonia (CAP) may improve morbidity, mortality and use of hospital resources. Worse outcomes from delayed intensive care unit (ICU) admission have long been suspected but have not been verified.


METHODS
In a retrospective study of consecutive patients with CAP admitted from 1996-2006 to the ICUs of a tertiary care hospital, we measured serial severity scores, intensive therapies received, ICU-free days, and 30-day mortality. Primary outcome was mortality. We developed a regression model of mortality with ward triage (and subsequent ICU transfer within 72 h) as the predictor, controlled by propensity for ward triage and radiographic progression.


RESULTS
Of 1059 hospital-admitted patients, 269 (25%) were admitted to the ICU during hospitalization. Of those, 167 were directly admitted to the ICU without current requirement for life support, while 61 (23%) were initially admitted to the hospital ward, 50 of those undergoing ICU transfer within 72 h. Ward triage was associated with increased mortality (OR 2.6, P = 0.056) after propensity adjustment. The effect was less (OR 2.2, P = 0.12) after controlling for radiographic progression. The effect probably increased (OR 4.1, P = 0.07) among patients with ≥ 3 severity predictors at admission.


CONCLUSIONS
Initial ward triage among patients transferred to the ICU is associated with twofold higher 30-day mortality. This effect is most apparent among patients with ≥ 3 severity predictors at admission and is attenuated by controlling for radiographic progression. Intensive monitoring of ward-admitted patients with CAP seems warranted. Further research is needed to optimize triage in CAP.
Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA. samuel.brown@imail.org
Samuel M
SM
Brown
Jason P
JP
Jones
Dominik
D
Aronsky
Barbara E
BE
Jones
Michael J
MJ
Lanspa
Nathan C
NC
Dean
D017714:Community-Acquired Infections / Q000000981:diagnostic imaging / Q000401:mortality*; D018450:Disease Progression; D005260:Female; D017052:Hospital Mortality; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D011014:Pneumonia / Q000000981:diagnostic imaging / Q000401:mortality*; D011859:Radiography; D012044:Regression Analysis; D012189:Retrospective Studies; D012720:Severity of Illness Index; D016896:Treatment Outcome; D014218:Triage