Marilyn Bromley, RN
Angela Franklin, JD

The Joint Commission/CMS performance measure for emergency departments’ treatment of pneumonia is being modified, and will now align with Infectious Diseases Society of America/American Thoracic Society (IDSA-ATS) consensus guidelines.

In 2004, the Joint Commission issued standard PN-5b, which requires giving patients an antibiotic within four hours of presentation if they present to an emergency department and are discharged with a diagnosis of pneumonia. Now, the Joint Commission plans to extend the time to administer an antibiotic to six hours (PN-5c).

The Joint Commission will also allow emergency physicians to document "diagnostic uncertainty" in to indicate that the diagnosis of pneumonia was not clear at the time of the patient’s arrival in the ED. Such cases will be excluded from the denominator when determining a hospital's performance on the measure. The Joint Commission stresses, however, that for the present data collection period: April 1, 2007 thru Sept 30, 2007, all three timing measures are in effect: the four- and eight-hour measures, and the six-hour test measure. The change will be reflected in the Joint Commission Specification Manual version 2.3, which will be effective for October 1, 2007 discharges.

Specifications for the six-hour antibiotic timing measure (PN-5c) were posted on the Joint Commission website in December 2006 and were incorporated into the Specifications Manual for National Hospital Quality Measures version 2.2 to be implemented with April 1, 2007 discharges. Because the measure was pending National Quality Forum (NQF) endorsement at that time, implementation was as a test measure. On April 20, 2007 NQF announced their endorsement of the PN-5c measure (Initial Antibiotic Received Within 6 Hours of Hospital Arrival). NQF’s endorsement of PN-5c replaces their past endorsement of the PN-5b measure (Initial Antibiotic Received within 4 Hours of Hospital Arrival). The Specification Manual version 2.3 effective for October 1, 2007 discharges removes the "test measure" designation for PN-5c.

The IDSA-ATS guidelines support the measure by clearly stating in the section on suggested performance measures: Initiation of treatment would be expected within 6 to 8 hours of presentation whenever the admission diagnosis is likely community acquired bacterial pneumonia (CAP). The Technical Expert Panel for the CMS National Pneumonia Project recommended the six-hour antibiotic timing measure in light of the measure modifications made listed below.

In addition to extending the window for initial administration of empiric antibiotic administration from four to six hours from hospital arrival, the Joint Commission and CMS have made the following revisions to the pneumonia antibiotic timing performance measure as a result of the expressed concerns respecting potential unintended consequences:

1. In July 2006, the Joint Commission added the data element "Chest X-ray" requiring the finding of a positive chest x-ray or CT scan during the hospitalization to confirm the diagnosis of pneumonia – those cases without a positive radiographic test are excluded from the measure.
   
   
2. Effective October 2006, the Joint Commission revised the data element Pneumonia Diagnosis: ED/Direct Admit and have given the following guidance to hospitals respecting abstraction:
   
   For pneumonia patients admitted through the ED:
   
   
   • ED physician documents pneumonia/infiltrate/pneumonitis (probable/suspected) as the ED final diagnosis/impression on the ED form or their ED dictation, answer "yes" to pneumonia diagnosis (regardless of who else sees patient).
     
     
   • ED physician does NOT document pneumonia/infiltrate/pneumonitis as the ED final diagnosis/impression.... but then that SAME ED physician turns around and writes the admit note or admit orders and gives a diagnosis of pneumonia, answer "yes" to pneumonia diagnosis.
     
     
   • ED physician does NOT document pneumonia/infiltrate/pneumonitis as the ED final diagnosis/impression.... but then a hospitalist/attending/consultant comes along and writes orders or an admit note with a diagnosis of pneumonia (whether the patient is still in the ED or not), answer "no" to pneumonia diagnosis (here the rationale for answering "no" was complaints from around the country that hospitals were being held accountable for timely delivery of antibiotics for patients that the ED physician never considered a diagnosis of pneumonia for – then an attending or hospitalist would come down several hours later and diagnosis pneumonia – long after the time frame for the antibiotic timing measure had passed)
     
     
   Essentially, this data element ensures that a case is not included in the denominator of the measure if the ED physician’s diagnosis is not pneumonia at the time the patient is discharged from the ED.
   
   
3. Added the data element "diagnostic uncertainty" and have given the following guidance for this data element: The primary intent of this data element is to determine if the physician identified clinical circumstances that would delay the diagnosis of pneumonia. The physician must specifically document the diagnostic picture was questionable or unclear and not suggestive of pneumonia, as noted by the following examples:
   
   
   • Clinical picture not clear
   • Diagnostic picture unclear
   • Not suggestive of pneumonia
   • No obvious signs of pneumonia
   • No overt evidence of pneumonia
   • Atypical presentation
   • Poor patient cooperation because of impaired mental status
     
     
   Because this is a specific data element, there is the ability to audit how frequently the data element is used to exclude patients from the denominator of the antibiotic timing performance measure in an effort to address potential "gaming" of the system.

References: The Joint Commission, JCAHO Tweaks Emergency Departments’ Pneumonia Treatment Standards, JAMA, April 25, 2007—Vol. 297, No. 16, pp 1758-1759.