Scenario

A patient with community acquired pneumonia presents to ER with cough and fever.

Based on assessment, the patient is candidate for inpatient treatment.

• 68 yo male smoker presents with 2 days of fever, chills, and productive cough.

• Evaluation:Left lower rales consistent with pneumonia.

• Orders in ER:CBC, Lytes, BUN, Cr and CXR. Pulse oximetry checked.

19:20 hrs, ED at UNMC, Omaha

Roger Dogeman, DOB 03/04/1938

Summary @ 20:14 hrs

Poor respiratory function,Fever,

Anemia,r/o infection,

Renal insufficiency

68

Chest X-rays

PA view of the chest shows dense opacity in the left lower lobe, consistent with pneumonia.

PA

Chest X-rays

The loss of the left hemidiaphragm ("silhouette sign") and preservation of the left heart border, indicates involvement of the left lower lobe and sparing of the lingula of the left upper lobe.

Lateral

MD records Problem, 20:53 hrs

The SAGE Engine is triggered by this event.

Initial Medications List

Initial Problem List

PSI Inquiries

SAGE determines PSI

Given new observations, SAGE thendetermines PSI score.

Image from: Pneumonia Severity Index Calculator. December 2003. Agency for Healthcare Research and Quality. Rockville, MD. http://pda.ahrq.gov/psicalc.asp

Class: IVScore: 98Mortality: 9.5%

Outpatient Rx

ICU Admit

Non-ICU AdmitSAGE

Guideline

Engine

PSI calculation usesrecord, labs, andclinician inputs.

Three possibletreatment outcomes.

SAGE now ready to use PSI score to make triagerecommendation.

SAGE Guideline Logic inProtégé

Outpatient Rx

ICU Admit

Non-ICU AdmitSAGE

Guideline

Engine

PSI calculation usesrecord, labs, andclinician inputs.

Choice is made to treat as Non-ICU inpatient.

Inpatient Logic

Now two actionsto be taken:

1) JCAHO measures,

2) Admissionorders.

CMS & JCAHO Specific Measures

Clinicians are asked these questions since data not available from EMR:

Pneumococcal vaccination up to date?Influenza vaccination up to date?At risk for pseudomonas?Transferred from outside?Previous antibiotics for CAP prior to arrival?Blood cultures obtained prior to arrival?Comfort measures only?

Blood Culture Timing

Has it been

done?

Set up reminders

.

Antibiotic Timing

Pending Top Level Order Set

Top Level

Consults

Lab

Med Rx for Pneumonia