Ambulant erworbene Pneumonie in der Notfallmedizin – Sind Diagnostik- und Behandlungsstandards in der Notaufnahme hilfreich?

 

 Permissions and Reprints

Zusammenfassung

Patienten mit ambulant erworbener Pneumonie (communityacquiredpneumonia, CAP) weisen eine hohe Krankenhaussterblichkeit auf. Die initiale Diagnosefindung, Risikostratifizierung und der Beginn der Therapie bei CAP findet meist in Notaufnahmen statt. In Deutschland ist die Akutversorgung in der Notaufnahme sehr heterogen strukturiert und bisher unzureichend standardisiert. Deshalb sind Projekte zur Verbesserung der notfallmedizinischen Versorgung in der innerklinischen Notfallversorgung erforderlich. Standardisierte Diagnostik- und Behandlungsprotokolle identifizieren Patienten mit erhöhtem Risiko, um zeitnah eine adäquate Therapie zu ermöglichen. Als Teil des etablierten nationalen CAP-Qualitätssicherungsprogramms verwenden wir den CRB-65-Score für die initiale Risikostratifizierung. In eigenen Untersuchungen konnte gezeigt werden, dass die Implementierung leitlinienadaptierter Diagnose-, Risikostratifizierungs- und Therapiestandards (CAP managementbundle) die Qualität der Versorgung betroffener Patienten signifikant verbessert und die Krankenhaussterblichkeit relevant reduziert. Die Krankenhausaufenthaltsdauer und die Verweildauer auf der Intensivstation wird dadurch ebenfalls vermindert, was mit einer Optimierung erlösrelevanter Kenndaten assoziiert ist.

Abstract

Community acquired pneumonia (CAP) is associated with high in-hospital mortality. The initial correct diagnosis, risk assessment and initiation of treatment are responsibilities of the emergency department (ED). In Germany, emergency medicine is not well established nationwide and organized in a very heterogeneous manner. Therefore, systematic approaches to improve quality of care are scarce and standardisations of processes are required. Standardized care bundles for CAP identify patients at increased risk for an adverse outcome. Early detection of CAP in the emergency department is essential for initiating timely and appropriate treatment. As part of the nationwide CAP quality improvement program we use CRB-65 for initial risk stratification in the ED. In own investigations we demonstrated that implementation of systematic guideline based care bundles for pneumonia significantly improves quality of care in the ED subsequently leading to decreased mortality during hospitalization. Early standardized care bundles in the ED reduce length-of-stay in the hospital and the intensive care unit. Furthermore, those strategies are accompanied with an improvement of economic characteristics.

• Literatur

• 1 Hoffken G, Lorenz J, Kern W et al. Epidemiologie, Diagnostik, antimikrobielle Therapie und Management von erwachsenen Patienten mit ambulant erworbenen unteren Atemwegsinfektionen sowie ambulant erworbener Pneumonie – Update 2009. S3-Leitlinie der Paul-Ehrlich-Gesellschaft für Chemotherapie, der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin, der Deutschen Gesellschaft für Infektiologie und vom Kompetenznetzwerk CAPNETZ. Pneumologie 2009; 63
  PubMedGoogle Scholar
• 2 Mandell LA, Marrie TJ, Grossman RF et al. Summary of Canadian guidelines for the initial management of community-acquired pneumonia: an evidence-based update by the Canadian Infectious Disease Society and the Canadian Thoracic Society. Can J Infect Dis 2000; 11: 237-248
  PubMedGoogle Scholar
• 3 Ewig S, Birkner N, Strauss R et al. New perspectives on community-acquired pneumonia in 388406 patients. Results from a nationwide mandatory performance measurement programme in healthcare quality. Thorax 2009; 64: 1062-1069
  CrossrefPubMedGoogle Scholar
• 4 Fine MJ, Smith MA, Carson CA et al. Prognosis and outcomes of patients with community-acquired pneumonia. A meta-analysis. JAMA 1996; 275: 134-141
  CrossrefPubMedGoogle Scholar
• 5 Kothe H, Bauer T, Marre R et al. Outcome of community-acquired pneumonia: influence of age, residence status and antimicrobial treatment. EurRespir J 2008; 32: 139-146
  PubMedGoogle Scholar
• 6 Pletz MW, Welte T, Ott SR. Advances in the prevention, management, and treatment of community-acquired pneumonia. F1000 Med Rep 2010; 2: 53-53
  PubMedGoogle Scholar
• 7 Cook DJ, Meade MO, Hand LE et al. Toward understanding evidence uptake: semirecumbency for pneumonia prevention. Crit Care Med 2002; 30: 1472-1477
  CrossrefPubMedGoogle Scholar
• 8 Wilson SJ, Wong D, Clifton D et al. Track and trigger in an emergency department: an observational evaluation study. Emerg Med J 2013; 30: 186-191
  CrossrefPubMedGoogle Scholar
• 9 McIntosh KA, Maxwell DJ, Pulver LK et al. A quality improvement initiative to improve adherence to national guidelines for empiric management of community-acquired pneumonia in emergency departments. Int J Qual Health Care 2011; 23: 142-150
  CrossrefPubMedGoogle Scholar
• 10 Hortmann M, Heppner HJ, Popp S et al. Reduction of mortality in community-acquired pneumonia after implementing standardized care bundles in the emergency department. Eur J Emerg Med 2013;
  PubMedGoogle Scholar
• 11 Christ M, Dodt C, Geldner G et al. Professionalisierung der klinischen Notfallmedizin – Gegenwart und Zukunft. AnasthesiolIntensivmedNotfallmedSchmerzther 2010; 45: 666-671
  PubMedGoogle Scholar
• 12 Gao F, Melody T, Daniels DF et al. The impact of compliance with 6-hour and 24-hour sepsis bundles on hospital mortality in patients with severe sepsis: a prospective observational study. Crit Care 2005; 9: 764-770
  CrossrefPubMedGoogle Scholar
• 13 Levy MM, Dellinger RP, Townsend SR et al. The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Intensive Care Med 2010; 36: 222-231
  CrossrefPubMedGoogle Scholar
• 14 Minton J, Clayton J, Sandoe J et al. Improving early management of bloodstream infection: a quality improvement project. BMJ 2008; 336: 440-443
  CrossrefPubMedGoogle Scholar
• 15 Rivers E, Nguyen B, Havstad S et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345: 1368-1377
  CrossrefPubMedGoogle Scholar
• 16 Schmidbauer W, Stuhr M, Veit C et al. Die Sepsis in der Notfallmedizin – Präklinische und frühe innerklinische Notfalltherapie. AnasthesiolIntensivmedNotfallmedSchmerzther 2013; 48: 524-530
  PubMedGoogle Scholar
• 17 Barlow G, Nathwani D, Williams F et al. Reducing door-to-antibiotic time in community-acquired pneumonia: Controlled before-and-after evaluation and cost-effectiveness analysis. Thorax 2007; 62: 67-74
  CrossrefPubMedGoogle Scholar
• 18 Blot SI, Rodriguez A, Sole-Violan J et al. Effects of delayed oxygenation assessment on time to antibiotic delivery and mortality in patients with severe community-acquired pneumonia. Crit Care Med 2007; 35: 2509-2514
  CrossrefPubMedGoogle Scholar
• 19 Christ M, Grossmann F, Winter D et al. Modern triage in the emergency department. DtschArzteblInt 2010; 107: 892-898
  PubMedGoogle Scholar
• 20 Strauss R, Ewig S, Richter K et al. The prognostic significance of respiratory rate in patients with pneumonia – a retrospective analysis of data from 705928 hospitalized patients in Germany from 2010–2012. DtschArzteblInt 2014; 111: 503-508
  PubMedGoogle Scholar
• 21 Hogan TM, Losman ED, Carpenter CR et al. Development of geriatric competencies for emergency medicine residents using an expert consensus process. AcadEmerg Med 2010; 17: 316-324
  PubMedGoogle Scholar
• 22 Singler K, Bertsch T, Heppner HJ et al. Diagnostic accuracy of three different methods of temperature measurement in acutely ill geriatric patients. Age Ageing 2013; 42: 740-746
  CrossrefPubMedGoogle Scholar
• 23 Christ-Crain M, Stolz D, Bingisser R et al. Procalcitonin guidance of antibiotic therapy in community-acquired pneumonia: a randomized trial. Am J RespirCrit Care Med 2006; 174: 84-93
  CrossrefPubMedGoogle Scholar
• 24 Bauer TT, Ewig S, Marre R et al. CRB-65 predicts death from community-acquired pneumonia. J Intern Med 2006; 260: 93-101
  CrossrefPubMedGoogle Scholar
• 25 McNally M, Curtain J, O'Brien KK et al. Validity of British Thoracic Society guidance (the CRB-65 rule) for predicting the severity of pneumonia in general practice: systematic review and meta-analysis. Br J Gen Pract 2010; 60: 423-433
  CrossrefPubMedGoogle Scholar
• 26 Capelastegui A, Espana PP, Quintana JM et al. Validation of a predictive rule for the management of community-acquired pneumonia. EurRespir J 2006; 27: 151-157
  PubMedGoogle Scholar
• 27 Lim WS, van der Eerden MM, Laing R et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 2003; 58: 377-382
  CrossrefPubMedGoogle Scholar
• 28 Aujesky D, Fine MJ. The pneumonia severity index: a decade after the initial derivation and validation. Clin Infect Dis 2008; 47 (Suppl. 03) 133-139
  CrossrefPubMedGoogle Scholar
• 29 Fine MJ, Auble TE, Yealy DM et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 1997; 336: 243-250
  CrossrefPubMedGoogle Scholar
• 30 Man SY, Lee N, Ip M et al. Prospective comparison of three predictive rules for assessing severity of community-acquired pneumonia in Hong Kong. Thorax 2007; 62: 348-353
  CrossrefPubMedGoogle Scholar
• 31 Aujesky D, Auble TE, Yealy DM et al. Prospective comparison of three validated prediction rules for prognosis in community-acquired pneumonia. Am J Med 2005; 118: 384-392
  CrossrefPubMedGoogle Scholar
• 32 Marti C, Garin N, Grosgurin O et al. Prediction of severe community-acquired pneumonia: a systematic review and meta-analysis. Crit Care 2012; 16
  PubMedGoogle Scholar
• 33 Ewig S, de Roux A, Bauer T et al. Validation of predictive rules and indices of severity for community acquired pneumonia. Thorax 2004; 59: 421-427
  CrossrefPubMedGoogle Scholar
• 34 Charles PG, Wolfe R, Whitby M et al. SMART-COP: a tool for predicting the need for intensive respiratory or vasopressor support in community-acquired pneumonia. Clin Infect Dis 2008; 47: 375-384
  CrossrefPubMedGoogle Scholar
• 35 Kruger S, Ewig S, Marre R et al. Procalcitonin predicts patients at low risk of death from community-acquired pneumonia across all CRB-65 classes. EurRespir J 2008; 31: 349-355
  PubMedGoogle Scholar
• 36 Schuetz P, Suter-Widmer I, Chaudri A et al. Prognostic value of procalcitonin in community-acquired pneumonia. EurRespir J 2011; 37: 384-392
  PubMedGoogle Scholar
• 37 Ugajin M, Yamaki K, Hirasawa N et al. Predictive values of semi-quantitative procalcitonin test and common biomarkers for the clinical outcomes of community-acquired pneumonia. Respir Care 2014; 59: 564-573
  CrossrefPubMedGoogle Scholar
• 38 Lacoma A, Bas A, Tudela P et al. Correlation of inflammatory and cardiovascular biomarkers with pneumonia severity scores. EnfermInfeccMicrobiolClin 2014; 32: 140-146
  PubMedGoogle Scholar
• 39 Julian-Jimenez A, Palomo de los Reyes MJ, ParejoMiguez R et al. Improved management of community-acquired pneumonia in the emergency department. ArchBronconeumol 2013; 49: 230-240
  PubMedGoogle Scholar
• 40 Pletz MW, Rohde G, Schutte H et al. Epidemiologie und Erreger bei ambulant erworbener Pneumonie (CAP). Dtsch Med Wochenschr 2011; 136: 775-780
  Article in Thieme ConnectPubMedGoogle Scholar
• 41 Christ M. Protokolle, Checklisten Notfall-/Intensivmedizin.Klinik für Notfallmedizin und Internistische Intensivmedizin Nürnberg 2014. Im Internet: http://www.notfallmedizin-nuernberg.de (Stand: Januar 2014)
  PubMedGoogle Scholar
• 42 Heppner HJ, Singler K, Kwetkat A et al. Do clinical guidelines improve management of sepsis in critically ill elderly patients? A before-and-after study of the implementation of a sepsis protocol. Wien KlinWochenschr 2012; 124: 692-698
  PubMedGoogle Scholar
• 43 Vardakas KZ, Siempos II, Grammatikos A et al. Respiratory fluoroquinolones for the treatment of community-acquired pneumonia: a meta-analysis of randomized controlled trials. CMAJ 2008; 179: 1269-1277
  CrossrefPubMedGoogle Scholar

• Supplementary Material