Effects of delayed oxygenation assessment on time to antibiotic delivery and mortality in patients with severe community-acquired pneumonia*

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Abstract
Practice guidelines suggest processes of care such as timely oxygenation assessment and antibiotic therapy as quality indicators for the management of community-acquired pneumonia. The objective of this study was to determine whether postponed oxygenation assessment (either by pulse oximetry monitoring or arterial blood gas analysis) delays initiation of antibiotic therapy and adversely affects intensive care unit survival in patients with severe community-acquired pneumonia. Secondary analysis from a prospective, observational, multicenter study including 529 patients with community-acquired pneumonia admitted to the intensive care unit in 33 hospitals. Delays in processes of care describe the interval between time of triage at hospital admission and either time to oxygenation assessment or start of antibiotic therapy. Postponing oxygenation assessment for >1 hr was associated with a significantly longer time to initiation of antibiotic therapy (median, 6 hrs [interquartile range, 3–9 hrs] vs. 3 hrs [2–5 hrs]; p < .001). Unadjusted linear regression analysis confirmed that a delay in oxygenation assessment of >1 hr was associated with an increase in time to first antibiotic dose of 6.13 hrs (95% confidence interval, 3.42–8.83; p < .001). In addition, a delay in oxygenation assessment of >3 hrs was associated with an increased risk of death (relative risk, 2.24; 95% confidence interval, 1.17–4.30). Multivariable analysis, adjusting for potential confounders, revealed that delayed oxygenation assessment (>3 hrs) was an independent risk factor of death (hazard ratio, 2.06; 95% confidence interval, 1.22–3.50). In this population of patients with severe community-acquired pneumonia, early oxygenation assessment was associated with more rapid antibiotic delivery and better intensive care unit survival. These data suggest the potential value of an early care bundle focusing on implementation of oxygenation assessment immediately after arrival to the emergency department.