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Scenario
A patient with community
acquired pneumonia
presents to ER with cough
and fever.
Based on assessment, the patient is
candidate for inpatient treatment.
19:20 hrs, ED at UNMC, Omaha
• 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.
Roger Dogeman, DOB 03/04/1938
Summary @ 20:14 hrs
68
Poor respiratory function,
Fever,
Anemia,
r/o infection,
Renal insufficiency
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 then
determines
PSI score.
Class: IV
Score: 98
Mortality: 9.5%
Image from: Pneumonia Severity Index Calculator. December 2003. Agency for Healthcare Research and Quality. Rockville, MD. http://pda.ahrq.gov/psicalc.asp
Three possible
treatment outcomes.
SAGE
Guidelin
e
Engine
PSI calculation uses
record, labs, and
clinician inputs.
Outpatient Rx
Non-ICU Admit
ICU Admit
SAGE
Guideline
Logic in
Protégé
SAGE now ready to use PSI
score to make triage
recommendation.
Choice is made to treat as
Non-ICU inpatient.
SAGE
Guidelin
e
Engine
PSI calculation uses
record, labs, and
clinician inputs.
Outpatient Rx
Non-ICU Admit
ICU Admit
Inpatient
Logic
Now two actions
to be taken:
1) JCAHO
measures,
2) Admission
orders.
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