Introduction Early radiological diagnosis is an important quality of care indicator in community acquired pneumonia (CAP), with evidence for negative impact of time to X-ray (TXR) >4 hours on length of stay and time to antibiotic administration¹. Despite growing concern about impact of out-of-hours admission on outcomes in a variety of acute medical conditions, there is little information on impact of time of day on processes of care in CAP in the UK. We analysed impact on TXR of out-of-hour’s admission via Emergency department (ED) versus Medical assessment unit (MAU) in a 1000 bed teaching hospital.

Methods Retrospective review of 300 consecutive adult admissions with radiologically confirmed CAP within a 3-month period. Data included point of entry to hospital, in-hours (08h00–16h00) versus out-of-hours admission, urgency of request, and time taken to order and perform CXR.

Results 210 patients (70%) were admitted via ED and 90 (30%) via MAU. Average TXR (TXR-Ave) overall was 3.20hrs and 80% had TXR < 4 hours. 72% of ED’s CXR requests were urgent vs. 56% in MAU (p=0.3). Daytime TXR-Ave in ED was significantly shorter than MAU (2.20 hrs vs. 3.30 hrs; p=0.0003). TXR-Ave in ED was 2.30 hours overall and was not significantly affected by admission out of hours. In contrast, after-hours admission via MAU was associated with significantly increased TXR-Ave (6.20hrs out-of- hours vs. 3.30 hrs in-hours; p=0.0001), and TXR > 4 hours (58% vs. 25%; p=0.0025). Time from request to performance of CXR was not significantly different in vs. out-of- hours, however average time from admission to requesting CXR in MAU was significantly longer out of hours vs. in-hours (4.57hrs vs. 2.03 hrs; p=0.0001).

Conclusions After- hours admission via MAU is associated with a significant increase in diagnostic delay in patients with CAP, largely attributable to delayed CXR requests. This may reflect delayed clerking due to reduced staffing after hours. Organisational and staffing factors associated with 4 hour ED trolley wait pressure may account for swifter and more consistent processes of care in ED. Further studies are required.

Reference

1. Bewick T et al; Clin Med. 2010 Dec; 10(6):563–7.