• pneumonia;
  • delays;
  • quality of care;
  • pay for performance;
  • time to antibiotics


  1. Top of page
  2. Abstract
  3. References

Objectives: The authors sought to determine the contribution of delays in care on time to antibiotics for patients admitted from the emergency department (ED) with pneumonia and to identify patients at risk for delayed antibiotics.

Methods: This was a retrospective cohort study of patients admitted to the Hospital of the University of Pennsylvania (HUP) and to Pennsylvania Presbyterian Hospital (Presbyterian) with an admission diagnosis of pneumonia in 2004.

Results: A total of 393 patients were included. Ninety percent had antibiotics documented as given in the ED. Eighty-three (43%) of 209 at HUP and 104 (64%) of 161 patients at Presbyterian received antibiotics within four hours. Patients who received antibiotics more than four hours after ED arrival experienced longer waits for radiograph orders (HUP, 54 min [95% confidence interval {CI} = 33 to 76 min]; Presbyterian, 43 min [95% CI = 29 to 58 min]), for radiograph performance (HUP, 21 min [95% CI = 4 to 39 min], Presbyterian, 24 min [95% CI = 8 to 47 min]), for antibiotic orders (HUP, 56 min [95% CI = 38 to 95 min]; Presbyterian, 67 min [95% CI = 33 to 103 min]), and for antibiotic administration (HUP, 28 min [95% CI = 17 to 39 min]; Presbyterian, 30 min [95% CI = 21 to 38 min]). Patients with lower severity scores (p = 0.005) and patients with nonclassic clinical presentations for pneumonia were at increased risk for delayed antibiotics (odds ratio, 2.2; 95% CI = 1.1 to 4.4).

Conclusions: Antibiotic delays for patients admitted with pneumonia occur across multiple care processes. Less severely ill patients and patients with nonclassic presentations are at higher risk for delayed antibiotic administration. Hospitals should consider performing a similar analysis to evaluate hospital-specific and patient-specific care delays.


  1. Top of page
  2. Abstract
  3. References
  • Agency for Healthcare Research and Quality, Rockville , MD . HCUPnet, Healthcare Cost and Utilization Project. http:hcup.ahrq.govHCUPnet.asp. Accessed Mar 8, 2006.
  • Joint Commission for Accreditation of Healthcare and Organization. Specification Manual for National Hospital Quality Measures. Oakbrook Terrace , IL : Joint Commission for Accreditation of Healthcare Organization, 2005.
  • Meehan TP, Fine MJ Krumholz HM, et al. Quality of care, process, and outcomes in elderly patients with pneumonia. JAMA. 1997; 278:20804.
  • Huock PM, Bratzler DW, Nsa W, Ma A, Bartlett JG. Timing of antibiotic administration and outcomes for Medicare patients hospitalized with community-acquired pneumonia. Arch Intern Med. 2004; 164:63744.
  • Joint Commission for Accreditation of Healthcare Organization. JCAHO Core Measure PN-5b. Specifications Manual for National Hospital Quality Measures. Oakbrook Terrace , IL : Joint Commission for Accreditation of Healthcare Organization, 2005.
  • Centers for Medicare and Medicaid Services. Medicare “Pay for Performance (P4P)” Initiatives. Available at: http:www.cms.hhs.govmediapressrelease.aspCounter1343. Accessed Mar 8, 2006.
  • Thompson D. The pneumonia controversy: hospitals grapple with the 4 hour benchmark. Ann Emerg Med. 2006; 47:25961.
  • Pines JM. Profiles in patient safety: antibiotic time and pay for performance. Acad Emerg Med. 2006; 13:78790.
  • Gilbert EH, Lowenstein SR, Koziol-McLain J, Barta DC Steiner J. Chart reviews in emergency medicine: Where are the methods? Ann Emerg Med. 1996; 27:3058.
  • Fine MJ, Auble TE Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997; 336:24350.
  • Derlet RW, Richards JR. Overcrowding in the nation's emergency departments: complex causes and disturbing effects. Ann Emerg Med. 2000; 35:638.
  • Derlet RW, Richards JR Kravitz R. Frequent overcrowding in US emergency departments. Acad Emerg Med. 2001; 8:1515.
  • Campbell SG, Murray DD, Hawass A, Urquhart D, Ackroyd-Stolarz S, Maxwell D. Agreement between emergency physician diagnosis and radiologist reports in patients discharged from an emergency department with community-acquired pneumonia. Emerg Radiol. 2005; 11:2426.
  • Rivers E, Nguyen B Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001; 345:136877.
  • McIntyre LA, Herbert PC Cook DJ, et al. Are delays in the recognition and initial management of patients with severe sepsis associated with hospital mortality? [abstract]. Crit Care Med. 2003; 31(1 Suppl):A75.
  • Gonzales R, Camargo CA Mackenzie T, et al. Antibiotic treatment of acute respiratory infections in acute care settings. Acad Emerg Med. 2006; 13:28894.
  • Aujesky D, Stone RA Obrosky DS, et al. Using randomized controlled trial data, the agreement between retrospectively and prospectively collected data compromising the pneumonia severity index was substantial. J Clin Epidemiol. 2005; 58:35763.