Identification of 90% of patients ultimately diagnosed with community-acquired pneumonia within four hours of emergency department arrival may not be feasible
ABSTRACT 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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ABSTRACT: Background: Enforcing the 4-hour rule for time to first antibiotic dose (TFAD) in patients with suspected community-acquired pneumonia (CAP) has been associated with increased antibiotic use and misdiagnosis for CAP in the emergency department (ED). We evaluated the impact of extending the TFAD window to 6 hours. Methods: All patients 21 years and older admitted with CAP diagnosis through the ED during the TFAD of 6-hour rule (January-June 2008) were compared to patients from periods of January to June 2003 (8-hour rule) and January to June 2005 (4-hour rule). Data included clinical characteristics, radiographic findings, severity of illness scores, admitting and final diagnosis concordance, process, and outcome measures. Results: A total of 659 patients were included. The TFAD within 6 hours improved in 2008 compared to the 2 previous periods (90.6% vs 80.4% in 2005 and 81.8% in 2003, P = 0.008). However, the concordance between final and admitting diagnosis of CAP did not improve in 2008 (64.3%) compared to that in 2005 (60.1%) and remained significantly lower than in 2003 (75.5%, P = 0.005). More antibiotics per patient were started in the ED in 2008 and 2005 compared to the period in 2003 (1.81 [0.55] and 1.68 [0.50] vs 1.45 [0.57], P < 0.001, respectively). Conclusions: Extending the process measure of TFAD from 4 to 6 hours was associated with increased compliance with this measure but did not lead to an improvement in reaching the correct diagnosis of CAP. Our data support the current guidelines from the Infectious Diseases Society of America and American Thoracic Society, which recommend prompt antibiotic administration in the ED when the diagnosis is made without mandating a specific period.Infectious Disease in Clinical Practice 01/2012; 20(1):58-62. DOI:10.1097/IPC.0b013e31823c4bb1
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ABSTRACT: Background Early antibiotic administration to patients diagnosed of community-acquired pneumonia (CAP) has been associated with a lower mortality. In the USA, its administration within four hours has been implanted as a quality standard. The objective of this work was to analyze, in a Spanish emergency department, the performance with patients with CAP, focusing on the administration of the first dose of antibiotic.Revista Clínica Española 10/2009; 209(9):409-414. DOI:10.1016/S0014-2565(09)72512-3 · 1.31 Impact Factor