ICU Utilization After Implementation of Minor Severe Pneumonia Criteria in Real-Time Electronic Clinical Decision Support

OBJECTIVES

To determine if the implementation of automated clinical decision support (CDS) with embedded minor severe community-acquired pneumonia (sCAP) criteria was associated with improved ICU utilization among emergency department (ED) patients with pneumonia who did not require vasopressors or positive pressure ventilation at admission.

DESIGN

Planned secondary analysis of a stepped-wedge, cluster-controlled CDS implementation trial.

SETTING

Sixteen hospitals in six geographic clusters from Intermountain Health; a large, integrated, nonprofit health system in Utah and Idaho.

PATIENTS

Adults admitted to the hospital from the ED with pneumonia identified by: 1) discharge International Classification of Diseases , 10th Revision codes for pneumonia or sepsis/respiratory failure and 2) ED chest imaging consistent with pneumonia, who did not require vasopressors or positive pressure ventilation at admission.

INTERVENTIONS

After implementation, patients were exposed to automated, open-loop, comprehensive CDS that aided disposition decision (ward vs. ICU), based on objective severity scores (sCAP).

MEASUREMENTS AND MAIN RESULTS

The analysis included 2747 patients, 1814 before and 933 after implementation. The median age was 71, median Elixhauser index was 17, 48% were female, and 95% were Caucasian. A mixed-effects regression model with cluster as the random effect estimated that implementation of CDS utilizing sCAP increased 30-day ICU-free days by 1.04 days (95% CI, 0.48-1.59; p < 0.001). Among secondary outcomes, the odds of being admitted to the ward, transferring to the ICU within 72 hours, and receiving a critical therapy decreased by 57% (odds ratio [OR], 0.43; 95% CI, 0.26-0.68; p < 0.001) post-implementation; mortality within 72 hours of admission was unchanged (OR, 1.08; 95% CI, 0.56-2.01; p = 0.82) while 30-day all-cause mortality was lower post-implementation (OR, 0.71; 95% CI, 0.52-0.96; p = 0.03).

CONCLUSIONS

Implementation of electronic CDS using minor sCAP criteria to guide disposition of patients with pneumonia from the ED was associated with safe reduction in ICU utilization.