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The 4-Hour Rule for Administering Antibiotics for CAP: Is It Possible?

Meeting the 90% threshold for the 4-hour antibiotic standard may not be feasible.

The Joint Commission on Accreditation of Healthcare Organizations and the Centers for Medicare and Medicaid Services (CMS) have established the administration of antibiotics within 4 hours as a core measure of quality for inpatients with a discharge diagnosis of community-acquired pneumonia (CAP), regardless of whether the diagnosis was established at the time of admission. Both organizations have based this standard on retrospective data that indicate a small decrease in inpatient and 30-day mortality. Many hospitals have adopted the University HealthSystem Consortium goal of 90% performance on these core measures.

In a retrospective chart review of a random sample of 152 patients who were admitted through a university emergency department and discharged with the diagnosis of CAP in 2005, the authors critically analyzed the records of the 53 patients (34.9%) who did not receive antibiotics within 4 hours of presentation. Of these 53 patients, 31 (58.5%) did not have a final ED diagnosis of CAP (representing 20.4% of the sample of 152 CAP patients). Seventy percent of the patients who did not receive antibiotics had CAP included in the ED differential diagnosis.

Comment: After much scrutiny, CMS retracted the initial CAP standard for blood cultures prior to antibiotics for all ED CAP patients, when it was clearly demonstrated that there was no proof of benefit. This study demonstrates that meeting the 90% threshold for the 4-hour antibiotic standard may not be possible when applied retrospectively for a diagnosis that may not have been possible to make while the patient was in the ED. But, that’s O.K. because emergency physicians are thick-skinned and more than accustomed to being held to the retrospectoscope. It would, however, be easier to take if real reproducible outcomes and benefits justified the standards . . . maybe next time. One wonders how many thousands of patients will receive unnecessary empirical antibiotics in the ED, as departments scramble to ensure that no patient who might actually have CAP falls outside the 4-hour rule.

— Richard D. Zane, MD, FAAEM

Published in Journal Watch Emergency Medicine March 23, 2007

Citation(s):

Fee C and Weber EJ. Identification of 90% of patients ultimately diagnosed with community-acquired pneumonia within four hours of emergency department arrival may not be feasible. Ann Emerg Med 2007 Jan 6; [Epub ahead of print]. (http://dx.doi.org/10.1016/j.annemergmed.2006.11.008)

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