Evidence in the ED The Port Study

1. Evidence in the EDThe Port Study Identifying Low Risk Patients with Community Acquired Pneumonia Zachary Meisel, MD, MPH

2. The PORT Study • Goals of Study: • Develop and validate a model for predicting prognosis for patients with community acquired pneumonia (CAP). • Improve decisions about hospitalizing patients with CAP with information readily available in ED or office. Fine MJ, Auble TE, Yealy DM. A prediction rule to identify low risk patients with community acquired pneumonia. N Engl J Med 1997; 336: 243-250

3. Patients with CAP The Rule (step 1) Age over 50? Yes No • Co-existing conditions: • Neoplastic disease • CHF • Cerebrovascular Disease • Renal Disease • Liver Disease Risk Class II-V Yes Yes Yes No Altered Mental Status Pulse >125 Resp Rate > 30/min SBP <90 mm Hg Temp less than 35 C or greater than 40 C Yes Risk Class I No

4. PORT prediction rule Step 2 • Identifies patients in risk classes II, III, IV, V. • Includes lab and xray findings • Total points by summing pt’s age and points for each characteristic. • Class II: <70 • Class III: 71-90 • Class IV: 91-130 • Class V: >130

5. Nursing home residence: 10 pts Neoplastic disease: 30 pts Liver disease: 20 pts CHF: 10 pts Cerebrovascular disease: 10 pts Renal disease: 10 pts Altered mental status: 20 pts Respiratory rate >30/min: 20 pts SBP <90: 20 pts Temp <35 or >40: 15 pts Pulse >125: 10 pts Arterial pH <7.35: 30 pts BUN >30 mg/dL: 20 pts Serum sodium <130 mmol/liter: 20 pts Glucose >250 mg/dL: 10 pts Hct <30%: 10 pts Pa02 <60 mm Hgb: 10 pts Pleural Effusion: 10 pts Prediction Rule Step 2

6. The Evidence • 3 phase study design • 54,000 patients used to derive, retrospectively validate, and then prospectively validate the rules. • Retrospective and prospective data used. • Outcomes evaluated: • Primary: 30 day hospital mortality • Secondary: repeat hospitalizations, intensive care unit admission, length of hospital stay.

7. Derivation of rules • Retrospective data • 14,000 inpatients from 1989 database • Included: patients >18 with primary diagnosis of CAP • Excluded: HIV or recent hospitalization • Outcome: 30 day hospital mortality

8. Validation of Rules • 39,000 patients evaluated from multihospital database • Retrospective • Inpatients • 2287 patients evaluated in “PORT cohort” • Prospective • Outpatients and Inpatients

9. Results

10. Results/Summary • Patients in risk class I, II and III have low risk from dying and other adverse events from CAP. • Outpatient or abbreviated inpatient therapy may be appropriate. • The prediction rule was consistent across the 2 retrospective cohorts as well as the prospective group.

11. HUPisms • Patients younger than 50 with CAP who have none of the coexisting illnesses or vital sign abnormalities listed in step one: • Can be classified into risk group I • Can most likely be safely discharged from the ED.

12. EM take home points • Patients who fail step 1, may need ancillary testing but still may be low enough risk to be discharged safely. • Patients who are hypoxic or unable to obtain follow up and/or antibiotics may require admission despite being classified as low risk under the PORT prediction rules