You are asked to review a 54-year-old female in the Emergency Department who has community acquired pneumonia. The chest X-ray shows multi-lobar consolidation.
Outline the factors that will influence your decision regarding admission to the Intensive Care Unit (ICU) for this patient.
Intensive Care admission will be required for this patient if they need:
The factors that will influence the decision to admit this patient include
1. The patient factors include:
Presence of one or more of these features may alter the balance of risk and therefore the inclination to admit to ICU
o A-a gradient, acidaemia, CO2
Severe Community acquired Pneumonia scoring systems
2. ICU Factors include
3. Hospital Factors
Medical, nursing staff and ancillary support staff (e.g., physiotherapy) capability of the ward
The decision to admit the patient to the ICU will depend on the intersection between how sick the patient currently is, the best prediction of the likely clinical course over the next 24 hours, the capacity of the ICU to admit further patients and the capacity of the ward in that particular hospital to care for a moderately unwell patient with the potential to deteriorate and require further invasive interventions.
Overall answered well, with good answers considering patients background morbidities as well as local hospital and ICU factors.
"local admission policy and culture" is an excellent euphemistic way of saying either "we are an obstructive and unhelpful ICU" or "we admit anything".
This question can be answered in a couple of different ways, depending on how you interpret it. One way would be to discuss the risk stratification (where patients at the greatest risk of death would be admitted to ICU), which would then lead to the discussion of whichever scoring systems you feel most comfortable with. The other way would be to start the discussion in terms of hospital resources and capacity. The college clearly wanted a large amount of the latter. Their model answer leaves little to improve upon. To be different in a totally arbitrary way which does not necessarily produce a better answer, one might reclassify the factors influencing ICU admission decisions into two broad groups: illness severity and resource requirement
In an idealised setting, with an infinite number of 1:1 nurses and single rooms, pneumonia severity would be the only factor which needs to be considered. The severity of pneumonia is assessed by means of various scoring systems, which attempt to predict mortality. These are worth discussing in detail.
Pneumonia severity scoring systems:
Of the possible risk stratification tools, one may need to commit to just one for the purposes of this question. There are many:
The college, in their answer to Question 18 from the first paper of 2012, used the IDSA/ATS document (to the extent that they cut and pasted the criteria directly into their model answer with zero modification). These are reproduced below:
Which of these tools is best? According to a 2010 meta-analysis by Chalmers et al, they are all much the same. Niederman (2009), in a narrative review, suggests that these tools mainly differ according to the intended application. The old PSI and the NICE guideline-recommended CURB65 score are both very good at identifying good for low-morality patients and there therefore better in the ED and the GP clinic. The IDSA/ATS guidelines and the SMART‐COP tool are probably better at identifying the patients at need of ICU care. For the purposes of completeness, the SMARRT-COP tool is included below:
In case you want to use it, the CURB 65 score is calculated by giving 1 point for each of the following prognostic features:
Patients are stratified for risk of death as follows:
Whichever guidelines you use, ICU admission should be considered for the high risk patients, i.e. those at greatest risk of mortality. One might also add that ICU admission would be inappropriate for patients in whom mortality is expected to be inevitable regardless of treatment, and that should probably also factor into the decision.
Lim, W. S., et al. "Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study." Thorax 58.5 (2003): 377-382.
Charles, Patrick GP, et al. "SMART-COP: a tool for predicting the need for intensive respiratory or vasopressor support in community-acquired pneumonia." Clinical Infectious Diseases47.3 (2008): 375-384.
Flanders, W. Dana, et al. "Validation of the pneumonia severity index." Journal of general internal medicine 14.6 (1999): 333-340.
Mandell, Lionel A., et al. "Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults." Clinical infectious diseases 44.Supplement_2 (2007): S27-S72.
Chalmers, James D., et al. "Severity assessment tools for predicting mortality in hospitalised patients with community-acquired pneumonia. Systematic review and meta-analysis." Thorax (2010): thx-2009.
Niederman, Michael S. "Making sense of scoring systems in community acquired pneumonia." Respirology 14.3 (2009): 327-335.