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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.

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    1. Scenario A patient with community acquired pneumonia presents to ER with cough and fever. Based on assessment, the patient is candidate for inpatient treatment.

    2. 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

    3. Summary @ 20:14 hrs 68 Poor respiratory function, Fever, Anemia, r/o infection, Renal insufficiency

    4. Chest X-rays PA view of the chest shows dense opacity in the left lower lobe, consistent with pneumonia. PA

    5. 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

    6. MD records Problem, 20:53 hrs The SAGE Engine is triggered by this event.

    7. Initial Medications List

    8. Initial Problem List

    9. PSI Inquiries

    10. Class: IV Score: 98 Mortality: 9.5% 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

    11. Three possible treatment outcomes. Outpatient Rx SAGE Guideline Engine Non-ICU Admit PSI calculation uses record, labs, andclinician inputs. ICU Admit

    12. SAGE Guideline Logic inProtégé SAGE now ready to use PSI score to make triage recommendation.

    13. Choice is made to treat as Non-ICU inpatient. Outpatient Rx SAGE Guideline Engine Non-ICU Admit PSI calculation uses record, labs, andclinician inputs. ICU Admit

    14. Inpatient Logic Now two actionsto be taken: • JCAHO measures, • Admissionorders.

    15. 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?

    16. Blood Culture Timing Set up reminders. Has it been done?

    17. Antibiotic Timing

    18. Pending Top Level Order Set

    19. Top Level

    20. Consults

    21. Lab

    22. Med Rx for Pneumonia