From the Guidelines
Patients with suspected pneumonia (PNA) should be referred to the emergency room if they exhibit severe symptoms or are at high risk for complications, as outlined in the guidelines for the management of adult lower respiratory tract infections 1. The decision to refer is based on the presence of severe symptoms such as tachypnoea, tachycardia, hypotension, and confusion, as well as the patient's risk of complications, including elderly patients with pneumonia and elevated risk of complications, patients with pneumonia who fail to respond to antibiotic treatment, and those with significant comorbidities 1. Key considerations for referral include:
- Respiratory distress (respiratory rate >30 breaths/minute)
- Hypoxemia (oxygen saturation <90% on room air)
- Hypotension (systolic blood pressure <90 mmHg)
- Altered mental status
- Inability to maintain oral hydration
- Significant comorbidities (such as COPD, heart failure, immunosuppression, or advanced age >65 years)
- Failed outpatient therapy
- Clinical deterioration despite appropriate antibiotics
- Multilobar involvement on imaging, pleural effusions, or empyema The CURB-65 or Pneumonia Severity Index criteria can be used to assess mortality risk and guide referral decisions 1. Immediate referral is crucial because severe pneumonia can rapidly progress to respiratory failure, sepsis, and multi-organ dysfunction, requiring prompt interventions like oxygen therapy, intravenous antibiotics, and possibly ventilatory support that aren't available in outpatient settings 1.
From the Research
Guidelines for Referring Patients to the ER for Possible PNA
- The decision to refer a patient to the ER for possible pneumonia (PNA) should be based on the severity of symptoms and the patient's overall health status 2, 3, 4.
- Patients with severe symptoms, such as high fever, difficulty breathing, or chest pain, should be referred to the ER immediately 3.
- Patients with underlying health conditions, such as heart disease or diabetes, may require closer monitoring and more aggressive treatment, and should be referred to the ER if their symptoms worsen or do not improve with treatment 2, 4.
- The following factors should be considered when deciding whether to refer a patient to the ER:
- Severity of symptoms
- Underlying health conditions
- Age and overall health status
- Response to initial treatment
- Studies have shown that patients with community-acquired pneumonia (CAP) who are treated with azithromycin or doxycycline in combination with beta-lactams have similar outcomes, and the choice of antibiotic should be based on susceptibility data from the treating facility 3, 4.
- Patients who do not respond to initial treatment or who have severe symptoms should be referred to the ER for further evaluation and treatment 2, 3, 4.