Fee Christopher, Weber Ellen J
Division of Emergency Medicine, Department of Medicine, University of California, San Francisco Medical Center, San Francisco, CA 94143, USA.
Ann Emerg Med. 2007 May;49(5):553-9. doi: 10.1016/j.annemergmed.2006.11.008. Epub 2007 Jan 8.
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.
我们要确定，使用当前医疗保健组织认证联合委员会（JCAHO）/医疗保险和医疗补助服务中心（CMS）的社区获得性肺炎核心指标标准，识别出随后获得医院出院诊断为社区获得性肺炎的90%急诊科（ED）患者是否可行。
这是一项在大学三级护理急诊科进行的回顾性病例系列研究。从2005年1月至12月间从医院出院且符合JCAHO/CMS社区获得性肺炎抗生素使用时机指标PN-5b的患者随机样本中，我们确定了通过急诊科入院且在到达医院4小时后才接受抗生素治疗的患者比例（异常值）。对异常值患者的病历进行审查，以确定他们是否最终被诊断为急诊科社区获得性肺炎。比较有和没有最终急诊科社区获得性肺炎诊断的异常值患者的表现特征，以确定可能解释在急诊科未能诊断社区获得性肺炎的特征。
在152例符合条件的急诊科社区获得性肺炎患者中，53例（34.9%）被确定为异常值。其中31例异常值患者没有最终的急诊科社区获得性肺炎诊断。因此，所有急诊科社区获得性肺炎患者中至少有20.4%（95%置信区间[CI]14.3%至27.7%）没有被诊断为急诊科社区获得性肺炎。在没有急诊科社区获得性肺炎诊断的异常值患者中，43.3%的胸部X光片异常，而有急诊科社区获得性肺炎诊断的患者中这一比例为95%（优势比24.8；95%CI 3.63至无穷大）。
使用当前的JCAHO/CMS标准，在急诊科评估期间可能无法识别出90%出院诊断为社区获得性肺炎的住院患者。因此，期望90%的此类患者在入院后4小时内接受抗生素治疗可能不现实。应该建立更现实的抗生素给药绩效标准，或者修改病例定义，使其仅包括最终被诊断为急诊科社区获得性肺炎或有客观临床和影像学证据的患者。
