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

doi:10.1016/j.annemergmed.2006.11.008

Annals of Emergency Medicine

Volume 49, Issue 5, May 2007, Pages 553-559

https://doi.org/10.1016/j.annemergmed.2006.11.008 Get rights and content

Study objective

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.

Methods

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.

Results

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 ∞).

Conclusion

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.

Introduction

The Centers for Medicare and Medicaid Services (CMS) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) have established antibiotic administration within 4 hours of hospital arrival as a core measure of quality care (PN-5) for admitted patients with community-acquired pneumonia and track the percentage of eligible patients who meet this measure (PN-5b).¹ Antibiotic administration within 4 hours was associated with a small reduction in inpatient and 30-day mortality in a large retrospective study of Medicare² patients and is now recommended by the Infectious Disease Society of America.³ The University HealthSystem Consortium has established achieving 90% performance on the core measures as goals. Our medical center has adopted this 90% guideline, with nonphysician staff bonuses dependent on this performance.

The current JCAHO/CMS PN-5b eligibility criteria are based on a hospital discharge diagnosis and not the final emergency department (ED) diagnosis, as long as there is a working diagnosis of community-acquired pneumonia documented before or at admission.⁴ If community-acquired pneumonia is listed at any point in the emergency physician’s differential diagnosis or in a note written by the admitting physician while the patient remains in the ED5, 6 and the patient is ultimately discharged from the hospital with “pneumonia,” the patient is eligible for the measure even in the absence of a final ED diagnosis of community-acquired pneumonia.

There is growing concern that to achieve an arbitrarily established, and financially rewarding, performance standard on the antibiotic timing measure, unnecessary antibiotics will be administered to patients who do not have community-acquired pneumonia,7, 8 which may expose patients to additional adverse effects and costs and may contribute to growing antibiotic resistance. Emergency physicians are particularly concerned about being held to a standard that is not achievable in a given period if the diagnosis does not require an objective finding on a study routinely obtainable in the ED.

This is a preliminary study whose aim is to determine whether it is feasible to identify, and therefore deliver antibiotics to, 90% of ED patients who are ultimately hospitalized and meet the current JCAHO/CMS community-acquired pneumonia core measures criteria. Additionally, to begin to understand why some patients may not be diagnosed with community-acquired pneumonia in the ED, we reviewed the presenting features of all those who missed the target, according to whether or not they received an ED diagnosis of community-acquired pneumonia.

Section snippets

Study Design

This is a retrospective case series of patients who presented through the ED and were discharged from an inpatient hospitalization with an International Classification of Diseases, Ninth Revision (ICD-9) discharge diagnosis of community-acquired pneumonia between January 1, 2005, and December 31, 2005. This study was approved by the Committee on Human Research at our institution.

Setting

The study was conducted at an urban university tertiary-care ED with an annual census of 39,000 patients in a

Results

Five hundred twenty patients met JCAHO/CMS core measure PN-5b eligibility criteria during the study period (Figure 1). Two hundred ninety-nine (57.5% of those eligible) were selected at random for JCAHO/CMS core measures analysis. One patient from the fourth quarter of 2005 was excluded after a change in ICD-9 coding classified the patient as an outpatient. Of the 299 patients, 58 were not admitted through the ED and 89 met JCAHO/CMS core measure PN-5b exclusion criteria, leaving 152 in the ED

Limitations

This is a small, single-center, retrospective study, and these findings may not apply to other settings. It is possible that other emergency physicians might have had different clinical impressions of the cases that did not have a final ED diagnosis of community-acquired pneumonia. Additionally, the study group was a sample of community-acquired pneumonia discharges, and it is possible that our subset was not representative of all cases in the hospital. However, this sample actually represents

Discussion

We have demonstrated that it may not be feasible to identify 90% of patients eligible for JCAHO/CMS core measure PN-5b while in the ED. In our center, we found that at least 20% of all community-acquired pneumonia patients admitted through our ED did not have a final ED diagnosis of community-acquired pneumonia. Thus, even if the effects of crowding, atypical patient presentations, and delays in nursing care could be overcome, it would be unrealistic to believe that one could deliver

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Joint Commission on Accreditation of Healthcare Organizations. Current specification manual for national hospital...
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Update of practice guidelines for the management of community-acquired pneumonia in immunocompetent adults
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Timing of antibiotic administration and outcomes for Medicare patients hospitalized with community-acquired pneumonia
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Respiratory infections account for 63.8% of infections met. Of which a quarter are lower respiratory tract: acute bronchitis, exacerbation of COPD or bronchiectasis and pneumonia. Acute bronchitis usually of viral etiology and in immunocompetent patients without comorbidity treatment is symptomatic with analgesics and anti-inflammatories. The main cause of exacerbation of COPD is the respiratory infection. The indication of empirical antibiotic choice and it is based on clinical criteria, the severity of the underlying disease, the severity of the exacerbation and the presence of risk factors for infection with Pseudomonas aeruginosa. The community-acquired pneumonia (CAP) is the leading cause of death by infection. The use of prognostic severity scales (PSI or CURB-65) is recommended for deciding where treatment is started, the tests to be performed for the etiological diagnosis and the recommended empirical antibiotic therapy. Patients with Healthcare Associated Pneumonia (HCAP) and nosocomial pneumonia (NP) have a higher risk of infection by multiresistant microorganisms (MMR) and increased morbidity and mortality. It requires specific empirical treatment depending on the severity of disease and risk factors for infection MMR.
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Citation Excerpt :
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Pneumonia antibiotic timing performance measures can result in unnecessary antibiotic administration to patients in whom a diagnosis of pneumonia remains possible but has not been confirmed.
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Time to antibiotic delivery in patients with diagnosis of pneumonia is a publicly reported quality measure.
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Retrospective case series studies of patients admitted to the hospital through the ED with diagnosis of community-acquired pneumonia were identified over a period of 48 months. Patients were included in the study if they met TJC/CMS PN-5 (antibiotic timing) criteria. We compared antibiotic delivery timing before and after implementation of PAT in moderate-acuity patients using Wilcoxon rank sum tests. A linear regression analysis was done to account for age, sex, ED volume, and acuity level.
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: Supervising editor: David A. Talan, MD

: Author contributions: CF conceived and designed the study and collected the data. CF and EJW drafted the article and contributed substantially to its revision. CF takes responsibility for the paper as a whole.

: Michael Callaham, MD, recused himself from the editorial decision process for this article.

: Funding and support: The authors report this study did not receive any outside funding or support.

: Reprints not available from the authors.

: Available online January 8, 2007.

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Infectious disease/brief research reportIdentification of 90% of Patients Ultimately Diagnosed With Community-Acquired Pneumonia Within Four Hours of Emergency Department Arrival May Not Be Feasible

Study objective

Methods

Results

Conclusion

Introduction

Section snippets

Study Design

Setting

Results

Limitations

Discussion

Ann Emerg Med.

Ann Emerg Med.

Update of practice guidelines for the management of community-acquired pneumonia in immunocompetent adults

Clin Infect Dis.

Timing of antibiotic administration and outcomes for Medicare patients hospitalized with community-acquired pneumonia

Arch Intern Med.

Infectious disease/brief research report
Identification of 90% of Patients Ultimately Diagnosed With Community-Acquired Pneumonia Within Four Hours of Emergency Department Arrival May Not Be Feasible