Each chart was reviewed independently by the reviewers, who were asked one key question, as follows: was there a potential reason for a delay of antibiotic administration other than quality of care? It was anticipated that such cases in which the answer was “yes” would generally be due to diagnostic uncertainty such that the diagnosis of pneumonia would likely not have been made soon enough to deliver antibiotics within 4 h. Inherent in this designation was acceptance of the premise that in the absence of diagnostic uncertainty or an unusual patient-related circumstance that prevented the timely delivery of antibiotics, a delay in antibiotic treatment represented a lapse in quality. canadian neighbor pharmacy online
After a pilot study of 10 charts, it became clear that there were patients in whom a diagnosis of pneumonia was unlikely to have been made within 4 h, but in whom a need for therapy with antibiotics would have been clear within 4h(ie, a patient who was more likely to have had a purulent exacerbation of chronic bronchitis [ie, COPD]). The reviewers felt that the ED physician could appropriately defer the choice of antibiotics to the admitting physician in such cases. This scenario was then allowed for in the reviewers’ responses. In patients who were critically ill with a probable infectious etiology, the reviewers felt that antibiotics should have been delivered within 4 h, even if the diagnosis of pneumonia was not clear.
After the independent reviews, there were conference calls during which the reviewers attempted to achieve consensus on any cases for which there were discordant responses. The reasons for opinions were solicited and recorded.
We also attempted to determine what clinical factors were associated with the timing of antibiotic administration and diagnostic uncertainty. The chart abstraction for these analyses was performed independently of the above-described review process. These analyses were performed with the a priori understanding that we had limited statistical power. Therefore, antibiotic administration timing was treated as both a dichotomous variable (ie, > 4 h or < 4 h) and as a continuous variable. The initial chest radiograph reports were recorded as either suggesting pneumonia or not.