title: Emergency department operational changes in response to pay-for-performance and antibiotic timing in pneumonia.
abstract: BACKGROUND
  The percentage of adult patients admitted with pneumonia who receive antibiotics within four hours of hospital arrival is publicly reported as a quality and pay-for-performance measure by the Department of Health and Human Services and is called PN-5b.
  
  
  OBJECTIVE
  To determine attitudes among physician leaders at emergency medicine training programs toward using PN-5b as a quality measure for pay for performance, and to determine what operational changes academic emergency departments (EDs) have made to ensure early antibiotic administration for patients with pneumonia.
  
  
  METHODS
  The authors administered an online questionnaire to 129 chairpersons and medical directors of 135 academic ED training programs in the United States on attitudes toward performance measurement in pneumonia and changes that academic EDs have made in response to PN-5b; one response was sought from each institution. Respondents were identified through the Society for Academic Emergency Medicine Web site and e-mailed five times to maximize survey participation.
  
  
  RESULTS
  Ninety chairpersons and medical directors (70%) completed the survey; 47% were medical directors, 51% were chairpersons, and 2% were medical directors and chairpersons. Forty-five (50%) did not agree that PN-5b was an accurate quality measure, and 61 (69%) did not agree that pay for performance targeting this measure would lead to improved pneumonia care. The most common strategy to address PN-5b was to provide information to providers on the importance of early treatment with antibiotics (n = 63; 70%). For patients with suspected pneumonia, 46 (51%) automate chest radiograph (CXR) ordering at triage, 37 (41%) prioritize patients with suspected pneumonia, and 33 (37%) administer antibiotics before obtaining CXR results. Overall ED changes include improved turnaround time for CXR (n = 33; 37%), prioritized CXRs over other radiographs (n = 13; 14%), and improved inpatient bed availability (n = 12; 13%). Of 13 strategies identified to improve PN-5b, the median number that programs have implemented is five (interquartile range, 5-7). All sites reported engaging in at least three operational changes to address PN-5b.
  
  
  CONCLUSIONS
  All EDs in this study have addressed early antibiotic administration with multiple operational changes despite mixed sentiment that these changes will improve care. Future research is needed to measure the impact of pay-for-performance initiatives.
authors.affiliation: Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA. pinesjes@uphs.upenn.edu
authors.forename: Jesse M
authors.initials: JM
authors.lastname: Pines
authors.forename: Judd E
authors.initials: JE
authors.lastname: Hollander
authors.forename: Hoi
authors.initials: H
authors.lastname: Lee
authors.forename: Worth W
authors.initials: WW
authors.lastname: Everett
authors.forename: Lori
authors.initials: L
authors.lastname: Uscher-Pines
authors.forename: Joshua P
authors.initials: JP
authors.lastname: Metlay
mesh_terms: D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D016009:Chi-Square Distribution; D017598:Efficiency, Organizational; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D006801:Humans; D010816:Physician Incentive Plans; D011014:Pneumonia / Q000188:drug therapy*; D011785:Quality Assurance, Health Care / Q000191:economics*; D019984:Quality Indicators, Health Care; D012044:Regression Analysis; D018709:Statistics, Nonparametric; D011795:Surveys and Questionnaires; D013997:Time Factors; D014481:United States
chemical_list: D000900:Anti-Bacterial Agents