Introduction Pneumonia continues to be associated with significant mortality.1 The diagnostic gold standard remains the Chest X-Ray (CXR). Quality indicators such as door-to-antibiotic or door-to-radiograph time are monitored as surrogate outcome measures.
Objective To assess the impact of CXR availability at first clinician contact in cases where initial antibiotics were delayed.
Methods We interrogated the time of initial consultation, radiographs and diagnosis for 57 CAP patients between March 2013 and February 2014 whose initial antibiotics were delayed beyond 4 h.
Results The median age was 77 (interquartile range 67–85), 32 (53%) were female. Presentation was to the ED in 45 (79%) and to the GP assessment unit (GPAU) in 12 (21%) cases. 37 (65%) cases had SIRS, 45% had a CURB-65 score of 3 or above.
CXR reports were compatible with pneumonia in 44 (77%) cases, but only 11 (19%) had a CXR at time of first doctor contact. Interestingly, a reported consolidation was not associated with an initial diagnosis of pneumonia (p = 1.0000, Fisher’s exact test, two-tailed p).
Median time to first clinician contact was 2:14 h (ED 2:03 h, GPAU 4:33 h). Overall, 20 patients (35%) had a diagnosis of pneumonia after the initial consultation, 7 (58%) in GPAU and 13 (29%) in the ED. CXRs were obtained within 4 h in 49 (86%) cases. Median time to diagnosis was 7:06 h (ED 8:35 h, GPAU 5:54 h). CXR availability at first clinician contact differed significantly – GPAU 50%/6 vs ED 11%/5 (p = 0.0068, Fisher’s exact test, two tailed p).
Discussion There were significant delays to diagnosis, despite most CXR reports indicative of pneumonia. The absence of a CXR on initial clinician contact may contribute to the poor diagnostic accuracy seen in this case series. Notably the 4 h door-to-radiograph target set by BTS was largely met. We will deploy the GPAU pneumonia care bundle in the ED, which was shown to improve door-to-radiograph time (CURECAP, reported previously2). The efficacy of this intervention will be the subject of further studies.
References 1 Gibson GJ, et al. Eur Respir J. 2013;42:559–563
2 Cunningham P, et al. Thorax 2013;68(Suppl 3):A186
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