title: Identification of 90% of patients ultimately diagnosed with community-acquired pneumonia within four hours of emergency department arrival may not be feasible.
abstract: 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 infinity).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Division of Emergency Medicine, Department of Medicine, University of California, San Francisco Medical Center, San Francisco, CA 94143, USA. christopher.fee@ucsfmedctr.org
authors.forename: Christopher
authors.initials: C
authors.lastname: Fee
authors.forename: Ellen J
authors.initials: EJ
authors.lastname: Weber
mesh_terms: D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D002140:California; D017714:Community-Acquired Infections / Q000175:diagnosis; D042241:Early Diagnosis; D004635:Emergency Medicine / Q000592:standards; D004636:Emergency Service, Hospital / Q000592:standards / Q000706:statistics & numerical data*; D006801:Humans; D010043:Outcome and Process Assessment, Health Care; D011014:Pneumonia / Q000175:diagnosis* / Q000188:drug therapy; D017410:Practice Guidelines as Topic; D019984:Quality Indicators, Health Care / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D013997:Time Factors
chemical_list: D000900:Anti-Bacterial Agents