Quality statement 2: Chest X‑ray and antibiotic treatment
Quality statement
Adults presenting to hospital with suspected community-acquired or hospital-acquired pneumonia receive chest X‑ray followed by antibiotic treatment if a diagnosis of pneumonia is confirmed, both within 4 hours of presentation. [2016, updated 2025]
Rationale
Early treatment of pneumonia is associated with improved clinical outcomes. Chest X‑ray should be undertaken to confirm the diagnosis and appropriate antibiotic treatment started as soon as possible, and within 4 hours of presentation at hospital.
Where a chest CT scan has already been performed, a chest X‑ray may not be needed. Lung ultrasound can be used as an adjunct to chest X‑ray, particularly in cases where it will be difficult to carry out chest X‑ray promptly. This should not replace chest X‑ray for confirming a diagnosis of pneumonia.
Although most people will develop hospital-acquired pneumonia while staying in hospital, some may present with hospital-acquired pneumonia 7 to 10 days after being discharged from hospital.
Quality measures
The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
Process
a) Proportion of adults discharged from hospital following an emergency presentation with community-acquired or hospital-acquired pneumonia who had a chest X‑ray within 4 hours of presentation.
Numerator – the number in the denominator who had a chest X‑ray within 4 hours of presentation.
Denominator – the number of adults discharged from hospital following an emergency presentation with community-acquired or hospital-acquired pneumonia.
Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records.
Note: Provision of a chest CT scan may negate the need for chest X‑ray, and this should be accounted for when measuring performance.
b) Proportion of adults discharged from hospital with a primary diagnosis of pneumonia who received antibiotic treatment within 4 hours of presentation at hospital.
Numerator – the number in the denominator who received antibiotic treatment within 4 hours of presentation.
Denominator – the number of people discharged from hospital with a primary diagnosis of pneumonia.
Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records.
What the quality statement means for different audiences
Service providers (secondary care services) ensure that systems are in place for provision of chest X‑ray and antibiotics within 4 hours for people presenting to hospital with community-acquired or hospital-acquired pneumonia.
Healthcare professionals (such as secondary care clinicians including doctors and nurses) ensure that adults presenting to hospital with suspected community-acquired or hospital-acquired pneumonia have a chest X‑ray to confirm diagnosis. When a diagnosis of community-acquired or hospital-acquired pneumonia is confirmed, they begin antibiotic treatment as soon as possible and within 4 hours of the person presenting to hospital. Hospital practitioners ensure that suspected sepsis is treated in accordance with sepsis guidance.
Commissioners ensure that they commission services in which adults presenting to hospital with suspected community-acquired or hospital-acquired pneumonia have a chest X‑ray to confirm diagnosis. When community-acquired or hospital-acquired pneumonia is diagnosed, the commissioned services give antibiotic treatment as soon as possible and within 4 hours of presentation to hospital.
Adults presenting to hospital with suspected community-acquired or hospital-acquired pneumonia have a chest X‑ray to confirm the diagnosis. If the diagnosis is confirmed, they start antibiotic treatment as soon as possible and within 4 hours of arriving at hospital.
Source guidance
Pneumonia: diagnosis and management. NICE guideline NG250 (2025), recommendations 1.4.1, 1.5.1 and 1.5.2
Definitions of terms used in this quality statement
Community-acquired pneumonia
Pneumonia that is acquired outside hospital, or within 48 hours of admission. Pneumonia that develops in a nursing home resident is included in this definition. When managed in hospital the diagnosis is usually confirmed by chest X‑ray. [NICE's guideline on pneumonia, terms used in this guideline]
Hospital-acquired pneumonia
Pneumonia that develops 48 hours or more after hospital admission and that was not incubating at hospital admission, or people who present to hospital with pneumonia but who have been discharged within the last 7 to 10 days. When managed in hospital, the diagnosis is usually confirmed by chest X‑ray. [NICE's guideline on pneumonia, terms used in this guideline]
Within 4 hours of presentation to hospital
The presentation time is the time that the person presents to hospital. This can be at the emergency department or another department they have been advised to present to, such as a same day emergency care unit.
The Emergency Care Data Set states that the urgent and emergency care activity start date and time is when handover occurs, or 15 minutes after the emergency ambulance arrives at the emergency department, whichever is the sooner, and this is the 'clock start' time. This is the time that can be used for measurement purposes for this quality statement for those arriving by ambulance.
The time the person books in on arrival at the emergency department, or other department, can be used for measurement purposes, if they do not arrive by ambulance. [Adapted from NHS England's Emergency Care Data Set and user guidance and expert opinion]