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Admission and Discharge Guideline

These recommendations serve as a guide and clinicians are encouraged to use clinical judgment to manage all cases.

These guidelines may change as per revision by Government of India.

Approach

         Diagnostic studies

         Patient stratification

         Pneumonia Severity Index

         Patients with asthma have increased risk of complications and may warrant hospital admission.

      •         Need for hospitalization

 

         In general, patients in risk Class I and II may be managed as outpatients. Outpatient management of patients in risk Class III may be considered after assessment of patient’s clinical condition, follow-up, and home environment.

         Need for admission to an intensive care unit

 

Typical diagnostic work-up

Vital signs

         Chest x-ray (PA and lateral)

         Complete blood count (CBC) with differential

         Basic metabolic panel

         Hepatic profile

         Pulse oximetry and/or ABG

 

In addition, the following are recommended for Risk Class III-V and should be considered for

Risk Class I-II:

         Blood cultures x 2

         Sputum for Gram's stain and culture

 

 

Additional diagnostics to consider:

         HIV test

         ECG-12 leads

         Immunocompromised (including HIV):

         Consider other causes of pneumonia (e.g. fungal, viral,TB, PCP)/secondary bacterial/atypical pneumonia and other diagnostics

 

 

Calculating risk score;

 

Characteristics

Points

 

Demographic factors

 

1.      Men

Age in years

2.      Women

Age in years minus 10

3.      Nursing home residents

+10

4.      Coexisting diseases

 

a)      Neoplastic Disease

+30

b)      Liver Disease

+20

c)      Congestive heart failure

+10

d)     Cerebrovascular Disease

+10

e)      Renal Disease

+10

 

Physical Examination

 

1.      Altered Mental Status

+20

2.      Respiratory rate >30/min

+20

3.      Systolic B.P. <90 mmhg

+20

4.      Temperature <35.C or >40.C

+15

5.      Pulse >125/min

+10

 

Investigation Findings

 

1.      Arterial PH < 7.35

+30

2.      Blood Urea Nitrogen  >30mg/dl

+20

3.      S. Na <130

+20

4.      Blood Sugar > 250mg/dl

+10

5.      Haematocrit < 30%

+10

6.      SPO2  <90%

+10

7.      Pleural Effusion

+10

 

 

 

 

 

Stratification of Risk Score;

 

Risk

Risk Class

Score

Mortality

 

Low

I

Based on Alogrithm

0.1%

Consider treatment as

outpatient

Low

II

<70

0.6%

Consider treatment as

outpatient

Low

III

71 – 90

0.9%

Consider hospitalization

Moderate

IV

91 - 130

9.3%

Admit to hospital

High

V

>131

27%

Admit to hospital

 

Start the treatment according to the treatment guidelines for Influenza A H1N1

 

 

In case of children, indications for hospitalization include

·         Hypoxemia (oxygen saturation consistently less than 90 percent in room air)

·         Dehydration, or inability to maintain hydration orally; inability to feed in an infant

·         Moderate to severe respiratory distress: respiratory rate >70 breaths/min in infants <12 months or >50 breaths/min in older children, difficulty breathing, apnea, grunting

·         Toxic appearance, which is more common in children with bacterial pneumonia, may

·         suggest a more severe course of pneumonia (e.g., cardiopulmonary compromise)

·         Underlying conditions that may predispose to a more serious course of pneumonia (e.g., cardiopulmonary disease), might be worsened by pneumonia (e.g., metabolic disorder), or might adversely affect response to treatment (e.g., immunocompromised host)

·         Presence of complications (e.g., effusion/empyema)

·         Failure of outpatient therapy (worsening or no response in 24 to 72 hours)

 

 

 

Criteria for IV to PO conversion

Clinical improvement in pulmonary signs and symptoms Afebrile or consistent improvement in fever over a 24-hour period WBC count normalizing.

Infection being treated does not require IV therapy.

GI absorption likely normal (absence of vomiting or abnormal GI anatomy) Ability to receive oral dosage form either orally or via tube (concomitant oral or via tube administration of other meds).

 

 

DISCHARGE CRITERIA

 

Evaluate for discharge based on the following criteria:

         Stable co-morbid illnesses and significant improvement in pneumonia

 

Should also fulfill the following criteria (unless baseline status):

         Temperature < 37.8°C (> 24 hours and in the absence of antipyretics)

         Pulse < 100 beats/min

         Respiratory rate < 24 breaths/min

         SBP > 90 mmHg

         O2 saturation > 90% (at room air)

         Ability to maintain oral intake

 

 

 

 

 

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