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Association between timing of intensive care unit admission and outcomes for emergency department patients with community-acquired pneumonia*

Renaud, Bertrand MD; Santin, Aline MD; Coma, Eva MD; Camus, Nicolas MD; Van Pelt, Dave MD, MSc; Hayon, Jan MD; Gurgui, Merce MD; Roupie, Eric MD; Hervé, Jérôme MD; Fine, Michael J. MD, MSc; Brun-Buisson, Christian MD; Labarère, José MD, PhD

doi: 10.1097/CCM.0b013e3181b02dbb
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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).

Design: Secondary analysis of the original data from two North American and two European prospective, multicenter, cohort studies of adult patients with community-acquired pneumonia.

Patients: 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.

Interventions: None.

Measurements and Main 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.

From the Department of Emergency Medicine (BR, AS, NC, JH), AP-HP, Groupe Hospitalier Henri Mondor-Albert Chenevier, Créteil, France; Servei d’Atenció Continuada USAC (EC), Institut Català d’Oncologia, Hospital Duran i Reynals, L’Hospitalet de Llobregat, Barcelona, Spain; Université Paris 12 (NC, CBB), Faculté de Médecine, Créteil, France; Department of Critical Care and Pulmonary Consultants (DVP), The Medical Center of Aurora, Aurora, CO; Department of Critical Care Medicine (JH), Centre Hospitalier Intercommunal de Poissy Saint-Germain, Saint-Germain-en-Laye, France; Department of Emergency Medicine (MG), Hospital de la Santa Creu I Sant Pau, Barcelona, Spain; Department of Emergency Medicine (ER), Centre Hospitalier Universitaire de Caen, Hôpital Côte de Nacre, Caen, France; Université de Caen-Basse Normandie (ER), Faculté de médecine, Caen, France; Center for Health Equity Research and Promotion (MJF), VA Pittsburgh Healthcare System, Pittsburgh, PA; Division of General Internal Medicine (MJF), Department of Medicine, University of Pittsburgh, Pittsburgh, PA; Réanimation Médicale (CBB), AP-HP, Groupe hospitalier Henri Mondor-Albert Chenevier, Créteil, France; Quality of Care Unit (JL), Centre Hospitalier Universitaire de Grenoble, Grenoble, France.

Supported, in part, by the Département de la Formation Continue des Médecins de l’Assistance Publique des Hôpitaux de Paris (AP-HP), the ARMUR (Association de Recherche en Médecine d’Urgence, Henri Mondor, Créteil) France, AQUARE (Association pour la QUAlité, la Recherche et l’Enseignement à l’Hôpital Saint-Joseph, Paris), GlaxoSmithKline France, and Direction de la Recherche Clinique d’Ile de France as part of the Programme Hospitalier de Recherche Clinique (grant no. AOM 89-145).

Dr. Renaud has received grants from GlaxoSmithKline. Dr. Labarere was supported by a grant from the Egide Foundation, Paris, France (Programme Lavoisier) and from the Direction de la Recherche Clinique at Grenoble University Hospital. The remaining authors have not disclosed any potential conflicts of interest.

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© 2009 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins