How to Recognize Clinical Stability in Hospitalize

8/3/2019 How to Recognize Clinical Stability in Hospitalize

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Days

1.Clinically

Unstable

A

2. Early Clinical

Improvement

B

3. Definitive ClinicalImprovement

C

Clinical improvement in CAP

SeverityofDis

ease

+

-


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1.Clinically

Unstable

2. Early Clinical

Improvement

3. Definitive ClinicalImprovement

Point of Clinical Stability

Clinical stability

SeverityofDis

ease

+

-

Days


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Criteria to define clinical stability

Cough

SOBCRP

PCT

WBCTemperature

Heart

Rate

Respiratory

Rate Lactate

I feel better

TFN alfa

SpO2

PaO2

SvO2


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1. Cough and shortness of air are

improving

2. Patient is afebrile for at least 8

hours

3. White blood cell count is

normalizing

4. PO intake and GI absorption

are adequate *


ATS 2001


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improving


hours


normalizing


are adequate *

1. Temperature 37.8C

2. Heart rate 100 bpm

4. Systolic blood pressure 90 mmHg

5. SaO2 > 90% or PaO2 > 60 on RA

3. Respiratory rate 24

6. Ability to maintain oral intake *

7. Normal mental status


ATS 2001 ATS 2007


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improving


hours


normalizing


are adequate *

1. Temperature 37.8C

2. Heart rate 100 bpm

4. Systolic blood pressure 90 mmHg

5. SaO2 > 90% or PaO2 > 60 on RA

3. Respiratory rate 24

6. Ability to maintain oral intake *

7. Normal mental status

The aim of the study was to compare the two criteria for clinical

stability in hospitalized patients with CAP


ATS 2001 ATS 2007


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Observational, retrospective study

Consecutive patients hospitalized with CAP (including HCAP)

Veterans Administration Medical Center of Louisville, Kentucky, US

June 2001 and March 2006

Community-Acquired Pneumonia Organization (CAPO) database

www.caposite.com

Methods

Criteria to define clinical stability were

evaluated daily during the first 7 days of

hospitalization.


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487 pts

Results


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487 pts

Results


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Results

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 > Day 7 or not

reached

0%

35%

30%

25%

20%

15%

10%

5%

ATS 2001

Patients

Time to clinical stability


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Results


reached

0%

35%

30%

25%

20%

15%

10%

5%

ATS 2001

Patients

ATS 2001 criteria

429 patients (88%)



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Results


reached

0%

35%

30%

25%

20%

15%

10%

5%

ATS 2001

Patients

ATS 2007



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Results


reached

0%

35%

30%

25%

20%

15%

10%

5%

ATS 2001

Patients

ATS 2007

ATS 2007 criteria

410 patients (84%)

ATS 2001 criteria

429 patients (88%)



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Results


reached

0%

35%

30%

25%

20%

15%

10%

5%

ATS 2001

Patients

ATS 2007

A discrepancy in identifying clinical stability within the first week

from admission = 301 pts (62%)


Ti t lini l t bilit


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ATS 2001

ATS 2007

> 7

Days

%o

f

pts


p = 0.001

> 7


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Clinical stability and outcomes


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Sensitivity

1- specificity

ATS 2001

AUC: 0.758

ATS 2007

AUC: 0.782



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Conclusions

1. ATS 2001 criteria seem to identify clinical

stability earlier than ATS 2007 criteria

2. Both criteria seem to perform similarly with

respect to a composite outcome


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Some speculations


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Days

Some speculations

Severityof

Disease


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Days

Some speculations

Severityof

Disease


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Days

Clinical Stability

Some speculations

ATS 2001

Severityof

Disease


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Days

Severityof

Disease

Clinical Stability

Clinical Improvement

Some speculations

ATS 2001

ATS 2007


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429 patients ATS 2001 criteria

Composite outcome: 12.3%

Vs.

410 patients ATS 2007 criteria

Composite outcome: 9%

p = NS

Clinical stability within 7 days and outcomes

How to Recognize Clinical Stability in Hospitalize

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