Implementation of admission decision support for community-acquired pneumonia - A pilot study

Study objectives: Considerable variation exists in hospital admission rates for patients with community-acquired pneumonia, Logic to determine need fo r admission has been proposed by several authors. We compared Intermountain Health Care pneumonia guideline recommendations for inpatient vs outpatien t care with actual physician decision making and clinical outcomes before v s after implementation. A secondary objective was to determine whether the pneumonia severity index predicts need for admission in this population. Design: Prospective study after implementation vs historic controls. Settin g: Four ambulatory, urgent-care facilities. Patients: Four hundred sixty-three immunocompetent adults with radiographic ally confirmed community-acquired pneumonia. Intervention: A pneumonia practice guideline including decision support log ic was implemented for a le-month period. Measurements and results: After implementation, physicians used the pneumon ia guideline form in 90% of cases, The percentage of patients admitted with in 30 days decreased from 13.6% to 6.4% (p = 0.01). Only five patients befo re (2.5%) and three patients after (1.1%, p = 0.3) guideline implementation required subsequent hospital admission within 30 days after initial outpat ient treatment. Only two deaths occurred in the study cohort, both outpatie nts before implementation. The positive predictive value was 14.4%, and the negative predictive value for admission was 98.8% after guideline implemen tation. Guideline recommendation for admission was more likely to be follow ed in patients with more risk factors and hypoxemia. Conclusions: Decreased admission rate was observed after implementation of admission decision support in combination,vith specific recommendations for outpatient antibiotic therapy. Favorable outpatient outcomes suggest that implementation of decision support was safe.