Pneumonia in the emergency room: making smarter decisions

Emergency rooms may be often overwhelmed, and in the heat of the moment, it is important to keep a cool head and yet be open to new recommendations that can help us make wise decisions.

Respiratory System & Pneumology, by Dr. Hubertus Glaser & Dr. Jörg Zorn

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Emergency rooms may be often overwhelmed, and in the heat of the moment, it is important to keep a cool head and yet be open to new recommendations that can help us make wise decisions. Emergency rooms are in distress, and the strain on their resources builds up. This situation is also caused by a proportion of cases impossible to ignore of “patients with minor ailments”, as internist Dr. Ilka Enger puts it. These cases, some estimates indicate, could be as high as one-third of emergency room arrivals. Such is the pressure of these minor cases clogging the emergency rooms, that Dr. Enger, chairwoman of the German Federal Association of Private Practitioners (German acronym: BVNF) supports the idea of an emergency fee.

Better to guide than to take in?

The topic of an emergency fee has been put aside for some time in Germany at least, and its efficiency is yet to be seen Yet, a constructive and apparently successful solution to the emergency room bottlenecks is underway at the central emergency department of the Frankfurt Höchst Hospital. At the joint counter of the emergency room and the medical on-call service, the patient is "guided to the appropriate level of care according to his or her clinical picture," as head physician Dr. Peter-Friedrich Petersen reports in an interview. This is a model project in cooperation with the Hessian Regional Ministry of Health and the Hessian Association of Statutory Health Insurance Physicians. The project is scheduled to run for two years, and three-quarters of a year have gone by the summer of 2018. It is unclear what will happen after the two-year project cycle nonetheless.

But to this point, the case of the Höchst Hospital signals that motivating patients to take more personal responsibility may be the right approach. This can be achieved with the provision of effective information, not only on diagnosis but on the existing information channels themselves. For example, it is important to tell patients about the existence of a medical on-call service and how to reach it. "My experience shows that many patients are not even aware that there is a medical on-call service. They assume that anyone who has pain or discomfort beyond our opening hours can only go to the emergency section", explained a colleague interviewed for this post. 

Smart decisions in the emergency room

Pneumonia and pulmonary embolism are among the most frequent reasons for seeking out emergency room attention. As the German Society for Internal Medicine (GSIM or German acronym: DGIM) has just announced in a press release, there are now also "Wise Decision Recommendations" (WDR, or in German, KEE) for the emergency department, including specific protocols for the management of pneumological issues such as for example the best options to consider for suspected cases of pulmonary embolism. The emergency admission WDR provides for seven positive and three negative recommendations.

The first positive recommendation is:

Which three forms are these again? 1st: outpatient, 2nd: nosocomial and 3rd: acquired under immunosuppression.

The second recommendation is:

The reason: The mortality rate for pneumonia cases has been up to Germany. "The early onset of antibiotic therapy is therefore crucial for survival," explained Prof. Claus Vogelmeier quoted in a GSIM/DGIM press release. The well-known Marburg pneumologist is the current chairman of the GSIM/DGIM for the 2018/2019 season.

How should the "immediate" antibiotic therapy be implemented?

"Immediate" means: administering a combination of various broad-spectrum antibiotics intravenously. But of course, remove "at least 2 pairs of blood cultures at separate puncture sites beforehand". This rules out incorrect diagnoses, for example, due to contamination at the sampling point," says Vogelmeier.

The DGIM has dedicated its own website (in German) to the Wise Decision Recommendations idea, where you can also find the recommendations for smart choices in the emergency room, including explanations.

Some may ask why are these sometimes self-evident recommendations even necessary to diffuse. "Especially in emergency medicine, it is very difficult to always have up-to-date guidelines and knowledge from all specialist areas within easy and immediate reach," explains cardiologist Prof. Gerd Hasenfuß from Göttingen in a press release. This is a relatable situation and one where many of us have experienced several times in an emergency context. Worth to mention, Dr.Hasenfuß is "Special Representative of the GSIM/DGIM for Digital Medicine and Smart Decisions. Quite a thematic combination hinting at the shape of things to come.

Vaccines are a smart choice!

Is there a wise recommendation to prevent some incidences of pneumonia from developing in the first place? The wise decisions database suggests:

This is the third of the five positive pneumatic recommendations. Unfortunately, the low vaccination rates show that the practical implementation of the medical state-of-the-art standards is not only a challenge in the emergency department but also in the overall, day-to-day application of medicine and preventive care.