PNEUMONIA Team Membership Clinical Departments: Emergency Medical Services, General Medicine Hospital Departments: 6 Northeast, 3NESW, Emergency Department, Medical Records, Quality and Resource Management, Center for Clinical Effectiveness

Opportunity for Improvement To improve the rates of quality measures specific to the Pneumonia National Hospital Quality Measures: –Antibiotic Timing –Blood Culture Collection –Oxygen Level Assessment –Pneumococcal Vaccination > 65 years –Adult Smoking Cessation Counseling

Goals Initial antibiotic administered within 4 hours of arrival at hospital Appropriate antibiotic administered Blood cultures collected prior to initial antibiotic dose Oxygen level assessed within initial 24 hours of arrival Pneumococcal Vaccine administered to patients > 65 years old prior to discharge Smoking Cessation Counseling completed prior to discharge

Plan Re-education to stakeholders regarding use of Pneumonia Standing Orders Place appropriate antibiotics in Omni-Cell in ED and as floor stock on units Develop Standing Order Policy for Pneumococcal and Influenza Vaccine administration to use system-wide –In-service inpatient units –Pilot project instituted on 6 NE October 2004-February 2005 for compliance

Percent Pneumonia - Blood Culture Prior to Antibiotics Month p chart Jan-04 (n= 31) Feb-04 (n= 21) Mar-04 (n= 18) Apr-04 (n= 13) May-04 (n= 19) Jun-04 (n= 11) Jul-04 (n= 11) Aug-04 (n= 7) Sep-04 (n= 16) Oct-04 (n= 14) Nov-04 (n= 11) Dec-04 (n= 8) UCL = Mean = LCL = Definition: Collection of blood culture prior to first dose of antibiotic / pneumonia patients who received blood cultures after arrival, and antibiotics within 36 hours after arrival. Data Source: Original data extracted from LUMC charts by RNs. Eighty four percent of pneumonia patients receive blood cultures prior to initial antibiotics

Definition: Pneumonia patients who receive initial antibiotic within 4 hours after hospital arrival / All pneumonia patients who received antibiotics within 36 hours after arrival. Data Source: Original data extracted from LUMC charts by RNs. Interventions are being planned for all LUMC patients to receive initial antibiotics within 4 hours of hospital arrival

Percent Month p chart Jan-04 (n= 46) Feb-04 (n= 37)Mar-04 (n= 28) Apr-04 (n= 19) May-04 (n= 28) Jun-04 (n= 18) Jul-04 (n= 17) Aug-04 (n= 12)Sep-04 (n= 20) Oct-04 (n= 23) Nov-04 (n= 19)Dec-04 (n= 12) National Hospital Quality Measures Oxygen Assessment for Pneumonia Patients LUMC pneumonia patients receive oxygen assessment as a standard of practice Definition: Pneumonia patients who had an assessment of arterial oxygenation by arterial blood gas measurement or pulse oximetry within 24 hours prior to or after arrival at the hospital / All pneumonia patients. Data Source: Original data extracted from LUMC charts by RNs.

Percent Pneumonia - Non-ICU Correct Antibiotic Selection Month p chart Jan-04 (n= 26) Feb-04 (n= 20)Mar-04 (n= 16) Apr-04 (n= 13) May-04 (n= 15) Jun-04 (n= 8) Jul-04 (n= 10) Aug-04 (n= 2)Sep-04 (n= 9) Oct-04 (n= 10) Nov-04 (n= 12) Dec-04 (n= 5) UCL = Mean = LCL = A team of physicians, nurses and pharmacists is working to ensure every patient receives recommended antibiotics Definition: Immunocompetent non-intensive care unit patients with pneumonia who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines. Data Source: Original data extracted from LUMC charts by RNs.

A team of physicians, nurses and pharmacists is working to ensure every patient receives recommended antibiotics Definition: Immunocompetent intensive care unit patients with pneumonia who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines. Data Source: Original data extracted from LUMC charts by RNs.

Pneumococcal vaccination has improved with recent interventions focused on all patients 65 years and older Definition: Pneumonia patients age 65 and older who were screened for pneumococcal vaccine status and were administered the vaccine prior to discharge, if indicated. Data Source: Original data extracted from LUMC charts by RNs.

A team of physicians, nurses and pharmacists is working to ensure every smoker receives advice Definition: Smokers receiving smoking cessation counseling / Pneumonia Patients who have smoked cigarettes at any time in the 12 months prior to hospital arrival. Data Source: Original data extracted from LUMC charts by RNs.

6 Northeast Pilot October 2004-February 2005 Screen patients 65 years and older for Pneumococcal Vaccination status N=367 Overall Score=71% Improvement noted in number of patients screened

Next Steps Improve initial antibiotic dose timing Improve blood cultures drawn prior to antibiotic administration timing Assemble multi-disciplinary task force to address issues related to proper antibiotic selection in Non-ICU and ICU patients