Jessica DeJonge Ferris State University

• In acute pneumonia patients does the administration of antibiotics within four hours of presentation provide increased positive patient outcomes compared to antibiotic treatment past the four hour recommended time frame?

• Search words used: • Pneumonia, CORE measures, patient outcomes, antibiotic administration timing • Search engines: • PubMed, CINAHL, Google Scholar

• Results of search: • Multiple articles found. Several showing the positive patient outcomes with rapid administration of antibiotics. Also, multiple articles discussing the consequences of the “rush” to administer antibiotics within a required timeframe.

• Article #1

• Article # 2

• Hospital-Reported data on the pneumonia quality Measure “Time to First Antibiotic dose” are not associated with inpatient mortality: Results of a nationwide crosssectional analysis. • Article found in Academic Emergency Medicine.

• Early administration of antibiotics does not shorten time to clinical stability in patients with moderateto-severe community-acquired pneumonia. • Article found in Chest Journal

• Article #1 • Peer reviewed academic journal • Authors credible affiliations Northwestern University, Feinberg School of Medicine

• Article #2 • Peer reviewed academic journal • Authors credible: affiliations with Department of Emergency Medicine, New York Methodist Hospital

Article #1 • Study was aimed at determining if the timing of administration of the first antibiotic in pneumonia patients was associated with a decrease in patient mortality.

Article #2 • Study hypothesis was “that door-to-needle time less than four hours would result in time to clinical stability reduction of 0.5 days”

Article #1 • Cross-sectional analysis- an observational study, the subjects of the study are researched without altering the environment. • This type of study can compare subjects at specific points of time, and can compare multiple variables

Article #2 • Prospective observational study- looks at outcomes experienced by subjects studied • the study subjects are observed over a specific amount of time.

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Article #1 95,704 adult Emergency Department admissions with a diagnosis of pneumonia Study patients were taken from 530 hospitals nationwide. T-test Chi-square test

Article #2 • Looked at a large metropolitan teaching hospital. • Four hundred nine patients with community acquired pneumonia were studied • Study group were patients over 21 diagnosed with pneumonia • Independent variable was triage to needle time/dependent variable was the time to clinical stability • Statistical analysis by two-tailed student t test, analysis of variance and multiple linear regression

Article #1 • “There was no association between publicly reported time to first antibiotics dose quality measure performance and pneumonia inpatient mortality”

Article #2 • “There were no statistically significant differences in time to clinical stability between the study groups” • “The administration of antibiotics within four hours does not reduce the time to clinical stability in adult patients with pneumonia”

• Neither of the articles have any ethical considerations • Patient care was not altered for the benefit of the study • Individuals studied had already received medical care and their outcomes were studied.

Article #1 • Large population studied from multiple hospitals across the nation • Analysis of findings did not provide evidence of bias • Population studied similar to general population, study could be repeated at other facilities and would likely provide same results.

Article #2 • Analysis of findings did not provide evidence of bias • Smaller population studied, but population was similar to general population and likely that larger scale study would provide similar findings. • One hospital studied-large metropolitan teaching hospital

Article #1 • Article published in peer reviewed journal • Eight of the authors are Medical Doctors and one is a PHD. • First hand report • Published in 2011 • Factual results identified-no personal opinions expressed • Main points are clearly stated

Article #2 • Article published in peer reviewed journal • Authors are all Medical Doctors affiliated with New York Methodist Hospital. • First hand report-analysis was done by the authors not a literature review. • Published in 2003-similar outcomes in studies conducted recently. • Results are factual according to study results, there is no personal opinions expressed within the text of the literature. • Main points are clearly stated

• “Community-acquired pneumonia is among the most frequent causes of hospitalization in the United States, and is the sixthleading cause of death overall” (Silber, Garrett, Singh, et.al., 2003). • Finding the appropriate care necessary to produce the best patient outcomes for pneumonia patients is in the best interest of health care. • The information found in these studies produces evidence of the need for further evaluation of the current requirements of antibiotics within four hours and further studies are warranted to find additional care necessary in these patients to achieve the best care possible.

• Results Communicated: • Academic Journal articles • The findings of the first article were presented at an annual meeting at the Society for Academic Emergency Medicine in 2010 • Implications: • Provides evidence of the need to re-assess the mandated time frame of treatment with antibiotics and find combined measures to increase positive patient outcomes at the National Standard of Care level

• In the care of pneumonia patients, does waiting for culture results and treating with the correct spectrum of antibiotics produce better patient outcomes compared to treating with generic antibiotics first and changing them according to culture results? • In the care of pneumonia patients, are better patient outcomes seen when patients are provided antibiotics within four hours only compared to patients who receive antibiotics in a timely manner and provided adequate caloric intake and fluid replacement?

• Administration of antibiotics in patients with pneumonia early in treatment is necessary to produce improved clinical outcomes • Mandating a time frame may result in unnecessary administration of antibiotics, contributing to antibiotic resistance • Careful consideration must be taken on the treatment of each individual patient and the medical interventions necessary. Not every patient fits in “the box”. When physicians are placed on a strict time frame and pay for performance limitations, the appropriate care for the individual patient may be overlooked.

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Silber, S., Garrett, C., Singh, R., Sweeney, A., Rosenberg, C., Parachiv, D. & Okafo, T. (2003). Early

administration of antibiotics does not shorten time to clinical stability in patients with moderate-tosevere community-acquired pneumonia. Chest Journal, 124(5), 1798-1804. doi: 10.1378/chest.124.5.1798 •

Quattromani, E., Powell, E., Khare, R., Cheema, N., Sauser, K., Periyanayagam, U., Pirotte, M., Feinglass, J. & Courtney, M. (2011). Hospital-reported data on the pneumonia quality measure “time to first antibiotic dose” are not associated with inpatient mortality: Results of a nationwide cross-sectional analysis. Academic Emergency Medicine, 18, 496-503. doi: 10.1111/j.1553-2712.2011.01053.x