1. PNEUMONIA Team Membership Salma Mohsin, MD Mary E. Altier, MSN, RN Clinical Departments: Emergency Medical Services, General Medicine Hospital Departments: 6 Northeast, 3NESW, 2 NE, 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 Core measure: Antibiotic Timing Appropriate Antibiotic Administered Blood Culture Collection Oxygen Level Assessment Pneumococcal Vaccination: > 65 years Influenza Vaccination: > 50 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 Influenza Vaccine administered to patients > 50 years old prior to discharge Smoking Cessation Counseling completed prior to discharge

4. Plan Improve initial antibiotic dose timing by providing appropriate antibiotics in Omni-Cell in ED and as floor stock in hospital Meet with resident staff regarding ordering medications as “STAT” or ‘NOW” for initial therapy Improve blood cultures drawn prior to antibiotic administration timing Revise Pneumococcal and Influenza Standing Order Policy after review of CDC recommendations and estimation of influenza vaccine supply is determined. Re-education of hospital units/departments

5. Plan Influenza Vaccination posters placed in patient rooms, general population areas and all Out-patient sites. (October-February) Vaccination audit project for proper screening for 2 NEWS, 3 NEWS, 6NE, 7SW. Analyze and provide unit and nurse specific performance data to managers Provide monthly outlier reports to stakeholders to identify trends and opportunities for improvement Provide monthly reports to units with department specific results Provide overall performance data to the Pneumonia Task Force, General Medicine Service Line, and National Hospital Quality Measures Committee

6. Next Steps Revise Standing Pneumonia Orders. Transition from CAP to general pneumonia Nursing Home Patient Initiative: Floors/ICU ED QI Project: On-going Participation on Stroke Team: Disease Specific Certification through JCAHO. Pneumovax Screening required. Standard verbiage for Smoking Cessation on discharge forms Smoking Task Force Reconvene Pneumovax/Influenza In-service to inpatient units Participation in the UHC Core Measures Networking Collaborative 2005-2006

7. 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. Analysis: LUMC pneumonia patients receive oxygen assessment as a standard of practice. LUMC performance is stable with an average of 100%.

8. 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. Analysis: LUMC performance is stable with an average of 84%. Recent performance appears promising. UCL = 110.54 Mean = 83.88 LCL = 57.22

9. 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. Analysis: LUMC performance is at 66%. A temporary improvement occurred from February to September 2005. A team of physicians and nurses are actively working to ensure that all patients with pneumonia receive initial antibiotics within 4 hours of arrival. UCL = 101.88 Mean = 66.42 LCL = 30.95

10. Definition: Immunocompetent 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. Analysis: LUMC performance is at 80%. LCL = 43.27 Measure specification change to address unique needs of healthcare associated pneumonia patients

11. 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. Analysis: There was a significant improvement with the implementation of standing orders for vaccine administration. Performance continues at 69%. UCL = 75.95 Mean = 32.99 UCL = 114.20 Mean = 68.85 LCL = 23.50 Vaccine standing orders implemented

12. Definition: Pneumonia patients age 50 and older who were screened for influenza vaccine status and were administered the vaccine prior to discharge, if indicated. Data Source: Original data extracted from LUMC charts by RNs. Analysis: LUMC performance is at 61%. National shortages of 2004/05 and local vaccine supply delay in October 2005 should be considered during analysis. Vaccine standing orders implemented 100 UCL = 97.20 Mean = 60.69 LCL = 24.18 Vaccine standing orders implemented

13. 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. Analysis: Performance is unstable; on average 50% of eligible patients are receiving counseling. Interventions were enacted in February 2006 for all LUMC patients who smoke to receive smoking cessation information. UCL = 126.61 Mean = 50.00