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Instability on Hospital Discharge and the Risk of Adverse Outcomes in Patients With Pneumonia
Ethan A. Halm, MD, MPH;
Michael J. Fine, MD, MSc;
Wishwa N. Kapoor, MD, MPH;
Daniel E. Singer, MD;
Thomas J. Marrie, MD;
Albert L. Siu, MD, MSPH
Arch Intern Med. 2002;162:1278-1284.
Background Investigating claims that patients are being sent home from the hospital
"quicker and sicker" requires a way of objectively measuring appropriateness
of hospital discharge.
Objective To define and validate a simple, usable measure of clinical stability
on discharge for patients with community-acquired pneumonia.
Methods Information on daily vital signs and clinical status was collected in
a prospective, multicenter, observational cohort study. Unstable factors in
the 24 hours prior to discharge were temperature greater than 37.8°C,
heart rate greater than 100/min, respiratory rate greater than 24/min, systolic
blood pressure lower than 90 mm Hg, oxygen saturation lower than 90%, inability
to maintain oral intake, and abnormal mental status. Outcomes were deaths,
readmissions, and failure to return to usual activities within 30 days of
discharge.
Results Of the 680 patients, 19.1% left the hospital with 1 or more instabilities.
Overall, 10.5% of patients with no instabilities on discharge died or were
readmitted compared with 13.7% of those with 1 instability and 46.2% of those
with 2 or more instabilities (P<.003). Instability
on discharge ( 1 unstable factor) was associated with higher risk-adjusted
rates of death or readmission (odds ratio [OR], 1.6; 95% confidence interval
[CI], 1.0-2.8) and failure to return to usual activities (OR, 1.5; 95% CI,
1.0-2.4). Patients with 2 or more instabilities had a 5-fold greater risk-adjusted
odds of death or readmission (OR, 5.4; 95% CI, 1.6-18.4).
Conclusions Instability on discharge is associated with adverse clinical outcomes.
Pneumonia guidelines and pathways should include objective criteria for judging
stability on discharge to ensure that efforts to shorten length of stay do
not jeopardize patient safety.
From the Department of Health Policy and Division of General Internal
Medicine, Mount Sinai School of Medicine, New York, NY (Drs Halm and Siu);
the Division of General Internal Medicine and Center for Research on Health
Care, University of Pittsburgh, Pittsburgh, Pa (Drs Fine and Kapoor); VA Pittsburgh
Center for Health Services Research, VA Pittsburgh Healthcare System, Pittsburgh
(Dr Fine); the General Medicine Division, Department of Medicine, Massachusetts
General Hospital and Harvard Medical School, Boston (Dr Singer); and the Department
of Medicine, University of Alberta, Edmonton (Dr Marrie).
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