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    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.
    Annals of emergency medicine 06/2007; 49(5):553-9. DOI:10.1016/j.annemergmed.2006.11.008 · 4.68 Impact Factor
  • Annals of emergency medicine 09/2007; 50(2):205-6. DOI:10.1016/j.annemergmed.2007.03.036 · 4.68 Impact Factor
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    ABSTRACT: We hypothesize that emergency department (ED) volume and increased patient complexity are associated with lower quality of care, as measured by time to antibiotics for patients being admitted with community-acquired pneumonia. This was a cross-sectional study at a university tertiary care hospital ED. Community-acquired pneumonia patients admitted from the ED and discharged between January 2004 and June 2005 were reviewed by our institution for The Joint Commission's antibiotic timing core measure. Medical records were abstracted for patient age, sex, race, mode of transport, arrival time, triage acuity, inpatient level of care, and arrival-to-antibiotic-administration times. Controlling for patient characteristics, multivariate logistic regression determined association of antibiotic administration within 4 hours of arrival, with total ED volume at the time of the community-acquired pneumonia patient's arrival, and with number of ED patients requiring admission at the time of arrival. Four hundred eighty-six patients were eligible for the study; antibiotic administration time was available for 405. Sixty-one percent of patients received antibiotics within 4 hours. Antibiotic administration within 4 hours was less likely with a greater number of patients (odds ratio 0.96 per additional patient; 95% confidence interval 0.93 to 0.99) and a greater number of patients ultimately admitted (odds ratio 0.93 per patient; 95% confidence interval 0.88 to 0.99) in the ED. The effect of additional patients was present below total ED capacity. As ED volume increases, ED patients with community-acquired pneumonia are less likely to receive timely antibiotic therapy. The effect of additional patients appears to occur even at volumes below the maximum bed capacity. Measures to ensure that quality targets are met in the ED should consider the impact of ED volume.
    Annals of emergency medicine 12/2007; 50(5):501-9, 509.e1. DOI:10.1016/j.annemergmed.2007.08.003 · 4.68 Impact Factor
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