Pneumonia with atypical symptoms: Risk of delays

Nursing documentation is key

Only 43%-64% of adult ED pneumonia patients in two Pennsylvania EDs got antibiotics within four hours as recommended by current guidelines, says a new study. In addition, researchers found that patients with atypical symptoms had the biggest risk for delays.1

"Atypical symptoms include the absence of respiratory complaints or focal lung findings, such as a nursing home patient with abdominal pain who ends up having an lower lobe infiltrate on abdominal CT, or an immunocompromised patient with fever without a cough who ends up having a pneumonia," says Jesse M. Pines, MD, MBA, the study's author and an ED attending physician at the Hospital of the University of Pennsylvania in Philadelphia.

Four-hour antibiotic administration in patients admitted with pneumonia is being measured by the Centers for Medicare & Medicaid Services (CMS) and soon will be tied to hospital reimbursement in a pay-for-performance program. "ED nurses should be aware of this," he says. "Delays in antibiotic administration can exist across all processes involved in the ED diagnosis and treatment of pneumonia." An example of a nursing delay is a delay in antibiotic administration after antibiotic order, he says.

To determine compliance in the pay-for-performance program, hospitals go by when antibiotics are marked as given by an ED nurse, says Pines. This determination is done by a retrospective chart review of patients who are discharged from the hospital with a primary diagnosis of pneumonia or a primary diagnosis of respiratory failure and a secondary diagnosis of pneumonia, and who meet other criteria as determined by Joint Commission and CMS, he explains. "Nursing documentation is important to these reviews," he says.

Some computerized information systems require that medications be signed off as given, but in order to meet federal performance standards, ED nurses should not wait to do this in the case of pneumonia, says Pines. Instead, document that the medications were given immediately after administration, he advises.

Make physicians aware that pneumonia is suspected, and consider ordering chest X-rays from triage, suggests Pines. "Because early antibiotic administration has been associated with improved outcomes, it is possible that early recognition and early treatment of pneumonia with antibiotics may improve care," he says.

Use criteria to speed treatment

At Virginia Commonwealth University Medical Center in Richmond, ED nurses use a tool to identify community-acquired pneumonia patients with inclusion or exclusion criteria. Standing orders are used for labs, with a goal to give antibiotics within four hours of presentation, says Steve R. Rasmussen, RN, CEN, clinical coordinator. (See pneumonia identification tool used by ED nurses.)

"Once identified, we stratify patients by assigning point values to patient characteristics criteria, calculate a 'risk class,' and determine a plan of care," he reports. "This form helps streamline the medical orders and fast track the patient into the treatment plan."

To expedite treatment, antibiotics now are stored in the ED for immediate use, reports Rasmussen. "The time it took to obtain an antibiotic order, send it to the pharmacy, prepare the medication, and administer it was prohibitive to our four-hour window," he says.

At Gwinnett Medical Center in Lawrenceville, GA, "We have put a lot of work into identifying patients who present with symptoms suggestive of pneumonia, getting blood cultures, and giving the first dose of antibiotic within four hours," says Denise Proto, RN, MS, CEN, nurse educator for emergency services.

Triage nurses use the following criteria: Altered mental status that is not drug- or alcohol-related, fever of over 100.5° without obvious source, difficulty breathing, and oxygen saturation less than 95%. If a patient presents with any of these symptoms, a "community-acquired pneumonia (CAP) alert" chest X-ray is ordered by the triage nurse. "We have trained the radiology technologists to alert the designated ED physician when a 'CAP Alert' X-ray has been completed," says Proto. "We identified that the radiology staff were the best ones to tell the physician that the X-ray was done, vs. an ED charge nurse trying to keep on top of that."

Compliance with antibiotic administration has been steadily improving since the new system was implemented in May 2006, she reports. "This has given us a chance to work through the kinks before the really busy cold and flu season hits," she says.


1. Pines JM, Morton MJ, Datner EM, et al. Systematic delays in antibiotic administration in the emergency department for adult patients admitted with pneumonia. Acad Emerg Med 2006; 13:939-945.


For more information about care of pneumonia patients in the ED, contact:

  • Jesse M. Pines, MD, MBA, Department of Emergency Medicine, Hospital of the University of Pennsylvania, Ground Ravdin, Philadelphia. E-mail:
  • Denise Proto, RN, MS, CEN, Nurse Educator, Emergency Services, Gwinnett Medical Center, Lawrenceville, GA. Phone: (678) 442-4414. E-mail:
  • Steve Rasmussen, RN, CEN, Clinical Coordinator, Emergency Department, Virginia Commonwealth University Medical Center, Richmond. Phone: (804) 828-7330. E-mail: