Email UpdatesThe Community-Acquired Pneumonia (CAP) CDS alert is based on the CURB-65 tool that assesses CAP severity and recommends site of care (e.g., hospital or home) based on five clinical factors: patient confusion, uremia, elevated respiratory rate, low blood pressure, and age 65 years or older. Emergency departments that have ready laboratory access use all five factors. Primary care practices that do not have quick turnaround laboratory access, use only four of risk factors (i.e., do not use uremia). Scores from 0-4 or 5 determine the appropriate site of care, with the higher score indicating a higher severity of illness. Also included are supplementary Guideline Elements Model (GEM) reports parsed from the Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) CAP guidelines. These GEM Reports help to identify situations where a patient may benefit from direct ICU admission, imaging evaluation or further investigation for specific pathogens whose presence may alter standard management decisions. These GEM reports can be further developed into coded CDS artifacts, if desired.
Artifact Creation and Usage
The CAP Patient Safety Clinical Decision Support Implementation Toolkit was developed by NORC at the University of Chicago and Yale University as part of an initiative by AHRQ to fund studies on how to improve patient safety in ambulatory care settings. The toolkit aims to improve ambulatory care safety through development and implementation of clinical decision support alerts for CAP to help clinicians determine the most appropriate site of care for patients with CAP. The GEM files were created by the NORC/Yale team outside of the AHRQ-funded toolkit work.
Information regarding the GEM files:
Design of clinical decision support (CDS) tools at the Yale Center for Medical Informatics make use of a transformation model summarized below:
• Synthesize Knowledge – combine results of systematic review of biomedical literature with experience and expertise of guideline developers to create narrative recommendations
• Formalize Knowledge – translate natural language recommendations into standardized formats that computers can process
• Localize Knowledge – introduce transformed knowledge into systems that influence care, considering local resources, workflow, technical capabilities, etc.
• Analyze Knowledge- examine effects and effectiveness of translated knowledge as CDS or QM.
Formalization activities make use of the ASTM-standard Guideline Elements Model (GEM) to transform synthesized guidance into a knowledge representation intermediate between narrative text and executable code. GEM provides more than 150 XML elements to parse guidelines text. Guidelines are parsed into the Guideline Elements Model using the GEM Cutter XML editor. Once transformed into XML, the “GEMified” knowledge is available for processing using XSLT (XML Transforms).and other XML tools.
The five attached files illustrate artifacts from the formalization process using guidelines for diagnosis of community-acquired pneumonia (CAP):
Cap_1_Recommendations shows the original text guidelines. They are labeled as “Conditional” statements if both conditions and actions are present or as “Imperative” statements if the actions are stated but the conditions are not immediately apparent.
Cap_2 shows more detail regarding the recommendations and related information such as the citation for the guideline publication, the purpose, the intended audience and evidence quality rating schemes. The conditional elements are further broken down into decision variables (Conditions) and actions. Several recommendations are restated in statement logic format (IF A (and/or B…THEN C and/or D.
Cap 3 summarizes the recommendations and displays them in an IF THEN format.
Cap_4 lists all the decision variables divorced from the narrative context to highlight vague and underspecified conditions. This view also facilitates identification of concepts that will require encoding in a standardized vocabulary.
Cap_5 lists the actions again separated from contextual cues to assure identification of ambiguous actions and facilitate coding in appropriate vocabularies.
Information regarding the GEM files:
• Community Acquired Pneumonia Clinical Decision Support Implementation Toolkit Handbook on how to use the toolkit (available here)
•Prototype of the CDS alert for electronic health records (vendor agnostic) for the ED (available here) and a short pamphlet on use of the alert in the ED (available here).
•Prototype for the CDS alert for electronic health records (vendor agnostic) for primary care (available here) and a short pamphlet on use of the alert in primary care (available here).
•Workflow diagrams of how the CAP alert can be integrated into ED (available here) or primary care workflows (available here).
•Training slide decks for the ED and primary care setting on how and when to use the CAP alert in the electronic health record and how to incorporate it into the workflow:
◦Emergency Department Setting (available here)
◦Primary Care Setting (available here)
Semi-structured text that describes the recommendations for implementation in CDS
Community acquired pneumonia is the eighth leading cause of death in the United States and one of the top most commonly missed diagnoses. CAP can be treated in the hospital or at home, depending on severity. According to the 2007 IDSA/ATS Consensus Guidelines on the Management of Community-Acquired Pneumonia In Adults, “almost all of the major decisions regarding management of CAP, including diagnostic and treatment issues, revolve around the initial assessment of severity.” These CDS artifacts aim to assist clinicians during the critical time period when an assessment of severity must be made to determine a course of treatment. (Source: https://www.thoracic.org/statements/resources/mtpi/idsaats-cap.pdf)
For use in adults age 18 years and older presenting to ambulatory care or emergency department settings with symptoms suggestive of possible community acquired pneumonia
Potential users of the toolkit and GEM reports include clinicians (e.g., physicians, advanced practice clinicians, nurses), administrators (e.g., medical directors, medical information officers, information technology staff, and practice managers) and those developing and implementing the CDS (e.g., Informaticists, information technology staff).
1. The AHRQ Toolkit and associated materials contain concise summaries of the IDSA/ATS Guidelines for CAP, including the use of the CURB-65 tool, in the form of Low Fidelity Prototypes, implementation guidance, and GEM Reports. The specific decision logic for a CDS artifact is not included.
2. "Substantial overlap exists among the patients whom these guidelines address and those discussed in the recently published guidelines for health care–associated pneumonia (HCAP). Pneumonia in non-ambulatory residents of nursing homes and other long-term care facilities epidemiologically mirrors hospital-acquired pneumonia and should be treated according to the HCAP guidelines. However, certain other patients whose conditions are included in the designation of HCAP are better served by management in accordance with CAP guidelines with concern for specific pathogens." (Source: https://www.thoracic.org/statements/resources/mtpi/idsaats-cap.pdf)
3. Recommendations #1-3 and #13-49 in the Guidelines on the Management of Community-Acquired Pneumonia in Adults are not expressed in this artifact.
Derived from the 2007 Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adult which was created to develop a unified CAP guideline document in response to confusion between existing guidelines. (Source: Mandell et al.)
Community-Acquired Pneumonia Clinical Decision Support Implementation Toolkit. Content last reviewed January 2018. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/hais/tools/ambulatory-care/cap-toolkit.html
Mandell LA, et al. Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. CID 2007; 44 Suppl 2S27-S72.
The Guideline Elements Model. Accessed at: http://gem.med.yale.edu/default.htm
Recommendation #4: Hospital Admission Decision: Severity-of-illness scores, such as the CURB-65 criteria (confusion, uremia, respiratory rate, low blood pressure, age 65 years or greater), or prognostic models, such as the Pneumonia Severity Index (PSI), can be used to identify
patients with CAP who may be candidates for outpatient treatment.
Strong
Level I evidence
Recommendation #5: Hospital Admission Decision: Objective criteria or scores should always be supplemented with physician determination of subjective factors, including the ability to safely and reliably take oral medication and the availability of outpatient support resources.
Strong
Level II evidence
Recommendation #6: Hospital Admission Decision: For patients with CURB-65 scores 2, more-intensive treatment—that is, hospitalization or, where appropriate and available, intensive in-home health care services—is usually warranted.
Moderate
Level III evidence
Recommendation #7: ICU Admission Decision: Direct admission to an ICU is required for patients with septic shock requiring vasopressors or with acute respiratory failure requiring intubation and mechanical ventilation.
Strong
Level II evidence
Recommendation #8: ICU Admission Decision: Direct admission to an ICU or high-level monitoring unit is recommended for patients with 3 of the minor criteria for severe CAP listed in table 4.
Moderate
Level II evidence
Recommendation #9: Diagnostic testing: In addition to a constellation of suggestive clinical features, a demonstrable infiltrate by chest radiograph or other imaging technique, with or without supporting microbiological data, is required for the diagnosis of pneumonia. Recommended diagnostic tests for etiology.
Moderate
Level III evidence
Recommendation #10: Diagnostic testing: Patients with CAP should be investigated for specific pathogens that would significantly alter standard (empirical) management decisions, when the presence of such pathogens is suspected based on clinical and epidemiologic clues.
Strong
Level II evidence
Recommendation #11: Diagnostic testing: Routine diagnostic tests to identify an etiologic diagnosis are optional for outpatients with CAP.
Moderate
Level III evidence
Patient presents to emergency department or primary care office setting with a chief complaint suggestive of possible pneumonia, e.g. cough, respiratory difficulties, respiratory distress, shortness of breath, malaise, confusion, pneumonia, etc.
| Patient is >=18 years of age |
None
| CAPPS-CDS Tool: CURB-65 for the Emergency Department Setting | ACTION CALCULATE CURB-65 Score, assigning 1 point each for confusion (based on a specific mental test or disorientation to person, place, or time), BUN level 17 mmol/L (20 mg/dL), respiratory rate 30 breaths/min, low blood pressure (systolic, <90 mm Hg; or diastolic, <60 mmHg), and age >=65 years INTERVENTION DISPLAY Notification to Provider: Estimated 30-day mortality rate (%) and recommended site of treatment based on CURB-65 Score. |
| CAPPS-CDS Tool: CRB-65 for the Primary Care Setting | ACTION CALCULATE CRB-65 Score, assigning 1 point each for confusion (based on a specific mental test or disorientation to person, place, or time), respiratory rate 30 breaths/min, low blood pressure (systolic, <90 mm Hg; or diastolic, <60 mmHg), and age >=65 years INTERVENTION DISPLAY Notification to Provider: Estimated 30-day mortality rate (%) and recommended site of treatment based on CRB-65 Score. |
These artifacts were piloted in an ED from 3/27/17-7/31/17 and a primary care practice from 3/23/17-7/31/17.
Additional details are available in the Final Report (available here)