1. 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

2. 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

3. 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

4. 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

5. 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) 50 60 70 80 90 100 110 120 UCL = 112.52 Mean = 84.44 LCL = 56.37 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

6. 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

7. 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) 99.990 99.995 100.000 100.005 100.010 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.

8. 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) 0 20 40 60 80 100 120 140 160 UCL = 115.10 Mean = 82.19 LCL = 49.29 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.

9. 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.

10. 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.

11. 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.

12. 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

13. 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