Identification of 90% of Patients Ultimately Diagnosed With Community-Acquired Pneumonia Within Four Hours of Emergency Department Arrival May Not Be Feasible

Department of Medicine, University of California, San Francisco, San Francisco, California, United States
Annals of emergency medicine (Impact Factor: 4.68). 06/2007; 49(5):553-9. DOI: 10.1016/j.annemergmed.2006.11.008
Source: PubMed


We determine whether it is feasible to identify 90% of emergency department (ED) patients who subsequently receive a hospital discharge diagnosis of community-acquired pneumonia using the current Joint Commission on Accreditation of Healthcare Organizations (JCAHO)/Centers for Medicare and Medicaid Services (CMS) community-acquired pneumonia core measures criteria.
This was a retrospective case series in a university tertiary care ED. From a random sample of patients discharged from the hospital between January and December 2005 who were eligible for JCAHO/CMS community-acquired pneumonia antibiotic timing measure PN-5b, we identified the proportion of patients admitted through the ED who received antibiotics more than 4 hours after hospital arrival (outliers). Medical records of outliers were reviewed to determine whether they received a final ED community-acquired pneumonia diagnosis. Presenting characteristics of outliers with and without final ED community-acquired pneumonia diagnoses were compared to determine feature(s) that might explain failure to diagnose community-acquired pneumonia in the ED.
Of 152 eligible ED community-acquired pneumonia patients, 53 (34.9%) were identified as outliers. Thirty-one of the outliers did not have a final ED community-acquired pneumonia diagnosis. Thus, at least 20.4% (95% confidence interval [CI] 14.3% to 27.7%) of all ED community-acquired pneumonia patients did not have an ED community-acquired pneumonia diagnosis. Of outliers without an ED community-acquired pneumonia diagnosis, 43.3% had an abnormal chest radiograph compared with 95% with an ED community-acquired pneumonia diagnosis (odds ratio 24.8; 95% CI 3.63 to infinity).
It may not be possible to identify 90% of hospitalized patients with a discharge diagnosis of community-acquired pneumonia during their ED assessment by using the current JCAHO/CMS criteria. It may therefore be unrealistic to expect that 90% of such patients will have antibiotics delivered within 4 hours of hospital presentation. A more realistic performance standard for antibiotic administration should be established or case definitions modified to include only patients with a final ED community-acquired pneumonia diagnosis or objective clinical and radiographic evidence.

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    • "In this realm of investigation, the inclusion criteria are often very broad and then the exclusion criteria are applied to pare down the number of cases that apply to the question of interest. It is not unusual to find that the study population remaining after the application of all exclusion criteria can range from 46 to 64% of the original number of included cases [1, 2, 6, 12, 16]. "
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    ABSTRACT: The Joint Commission (JC) has set a quality of care standard for emergency department (ED) patients diagnosed with community acquired pneumonia (CAP) that states that they are to receive antibiotics within six hours of presentation to the ED. Hospitals have been able to demonstrate that the majority of patients meet these criteria, yet there are still many who do not. Previously published studies have reported that there are several issues that contribute to prolonged times to antibiotic administration including ED crowding and atypical clinical presentations. This study was undertaken to identify factors existing early in the patient encounter that may be associated with failure to meet the Joint Commission's six-hour standard for antibiotic administration. This was an IRB-approved, retrospective observational study covering 36 months in an academic emergency department. All adults with an admission diagnosis of CAP were eligible but were excluded if their discharge diagnosis was not CAP, if hospitalized within the previous 14 days, or if HIV positive. Univariate analysis and multiple logistic regression with stepwise variable selection were performed comparing patients who met and did not meet JC standards. The analysis included demographics (age, sex), chief complaint at triage and to doctor (fever, dyspnea, cough, chest pain, weakness/fatigue, abdominal pain), presence of altered mental status, triage vital signs, co-morbidities, day of week and time of day of presentation. A total of 736 cases were eligible; 199 cases met exclusion criteria; 43 charts were unavailable; 494 were included in the study group (363 with complete antibiotic time records; 131 were incomplete). From the univariate analysis, respiratory rate (RR) and oxygen saturation were the only factors that met Bonferroni criteria for statistical significance when comparing those who met and did not meet the JC six-hour criteria (RR 25 ± 9 vs 22 ± 6 breaths/minute, respectively, P = 0.002; oxygen saturation 87 ± 10% vs 92 ± 5%, respectively, P < 0.001). Multiple logistic regression identified triage pulse rate, oxygen saturation, presence of altered mental status, hour of day, and day of week as variables associated with time to antibiotic administration. Chances for meeting the standard were increased by 10% for each 5-beat increase in pulse rate or 1% decrease in oxygen saturation. If the person exhibited altered mental status, they were > 3.5 times more likely to meet the 6-hour criteria. If they presented to ED between 3 PM and 10 PM chances of meeting criteria were reduced by about 65%. If they presented on a Thursday, chances improved 2.8 times. Compared to patients who did meet Joint Commission criteria, those who did not receive antibiotics within 6 hours were likely to have triage pulse rates and O(2) saturation levels closer to normal, thus contributing to diagnostic uncertainty. They were also likely to present to the ED at the most crowded time of day. Likelihood to meet JC criteria was improved if O(2) saturation was below normal, pulse rate was elevated, if they exhibited mental confusion, or if they presented to the ED very early or very late in the day, or on a lower census day.
    Journal of Clinical Medicine Research 10/2012; 4(5):338-45. DOI:10.4021/jocmr1092w
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    • "Despite numerous medical advances over the last several decades, pneumonia remains a leading, global cause of illness and mortality, and the majority of cases are community-acquired pneumonia (CAP) (Mandell et al., 2007;Venditti et al., 2009). CAP is difficult to diagnose because the clinical presentation and radiographic results are not distinctive or consistent (Fee and Weber, 2007;Hagaman et al., 2009;Lieberman et al., 2003;Plouffe and Martin, 2008). The progression, duration and degree of severity vary depending upon the etiology, as well as the underlying age, health and immunity of the patient (Jokinen et al., 2001;Luna et al., 2000;Mandell et al., 2007;Waites et al., 2005). "
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    ABSTRACT: Rapid, accurate diagnosis of community-acquired pneumonia (CAP) due to Mycoplasma pneumoniae is compromised by low sensitivity of culture and serology. Polymerase chain reaction (PCR) has emerged as a sensitive method to detect M. pneumoniae DNA in clinical specimens. However, conventional real-time PCR is not cost-effective for routine or outpatient implementation. Here, we evaluate a novel microfluidic real-time PCR platform (Advanced Liquid Logic, Research Triangle Park, NC) that is rapid, portable, and fully automated. We enrolled patients with CAP and extracted DNA from nasopharyngeal wash (NPW) specimens using a biotinylated capture probe and streptavidin-coupled magnetic beads. Each extract was tested for M. pneumoniae-specific DNA by real-time PCR on both conventional and microfluidic platforms using Taqman probe and primers. Three of 59 (5.0%) NPWs were positive, and agreement between the methods was 98%. The microfluidic platform was equally sensitive but 3 times faster and offers an inexpensive and convenient diagnostic test for microbial DNA.
    Diagnostic microbiology and infectious disease 03/2010; 67(1):22-9. DOI:10.1016/j.diagmicrobio.2009.12.020 · 2.46 Impact Factor
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