Guideline compliance improves pneumonia care
Safely send patients home
A study conducted by investigators from the University of Pittsburgh School of Medicine and the Pittsburgh Veterans Affairs Healthcare System showed that more intense implementation strategies for care of pneumonia patients than typically found in most EDs safely increased the proportion of low-risk patients who were successfully treated as outpatients.1
"Our goal was to get not-so-sick patients discharged to home," explains lead author Donald M. Yealy, MD, professor and vice chair of emergency medicine at the University of Pittsburgh.
All of the EDs agreed to follow uniform practice guidelines, which were based on expert consensus of national experts in pneumonia care. They were then randomly divided into three groups:
- In the low-intensity sites, practitioners also were asked to voluntarily develop quality improvement strategies for pneumonia care and received supportive literature.
- Moderate-intensity sites received the supportive literature and reminders and were mandated to develop quality improvement strategies for pneumonia care. Additionally, the moderate-intensity sites received on-site educational training sessions, which reinforced practice guidelines and offered in-depth training in pneumonia assessment.
- High-intensity sites received all low-intensity and moderate-intensity strategies and received real-time reminders, medical provider audits and feedback, and participated in site-specific ongoing quality improvement activities.
The low-intensity group represents the kind of practices that are commonly employed in EDs, notes Yealy. "Moderate-intensity would be very much like what happens when an outside regulatory body asks you to comply with certain standards," he explains. "High intensity is when there is an outside regulatory body, and folks inside the ED are really putting in special efforts."
According to the study, low-risk patients in moderate intensity (61%) and high intensity (61.9%) were significantly more likely to be treated as outpatients compared with those in the low-intensity (37.5%) group.
Manager, staff, have greater interaction
Another benefit of participation in the study was greater interaction between the ED manager and his staff, which led to better compliance with guidelines, according to Richard Heath, MD, FACEP, medical director of emergency services at University of Pittsburgh Medical Center (UPMC) Braddock, whose ED was one of the high-intensity groups.
He says, "We did see improvement in the measured items: getting blood cultures before antibiotics, getting antibiotics within eight hours of admission, and so forth."
Heath’s ED was one of 32 in Connecticut and southwestern Pennsylvania that participated in the yearlong, multicenter randomized trial. It involved more than 3,200 patients, all of whom were diagnosed with pneumonia but who posed varying risks of adverse outcomes from the disease.
Expanding standard practice
What changes did the ED at UPMC Braddock make as part of the study? "There was a lot more feedback to the physicians — mostly from me," says Heath. "The normal process would just be announcing that we are going to do a particular thing a particular way, and I would do that at regular department meetings. Sometimes, I would repeat it at two or three consecutive meetings."
For the study, in addition to his normal practice, Heath would repeat the most important information nearly every month, he says. This information would include the importance of getting a pulse oximetry reading on anyone with pneumonia, obtaining blood cultures early — before antibiotics were started, and getting antibiotics on board early. This sometimes involves what Heath calls "empiric treatment."
"You may give [antibiotics] to someone you suspect has pneumonia before you even know it," he says. "Once you make the diagnosis, if it has not been given, you give it right away."
When people did not receive care in the appropriate fashion, "I would take that particular chart not only to that physician, but to others on the staff — de-identified — and say, Look, we really need to do this in the timed fashion,’" Heath says. "And I’d say to the doc, Here’s what we’re trying to get to. Let’s look at why we didn’t.’"
A little reverse psychology helped with compliance, says Heath. "Most line docs do not want to hear from the director all time, so they modified their behavior on their own — which led to them doing the desired behavior," he observes.
Anticipating CMS
Many of the guidelines seemed to anticipate the core measures recently set out by the Centers for Medicare & Medicaid Services, "so we’re generally continuing the same functions — with an even greater need to do empiric antibiotics," Heath says. The hospital has picked up the chart review process and is using it throughout the facility, he adds.
What global messages did the study have for ED managers? "It takes effort to change physician and nursing behavior, but with that effort, you can change behavior and get more adherence to protocols," says Yealy.
Reference
- Yealy DM, Auble TE, Stone RA, et al. Effect of increasing the intensity of implementing pneumonia guidelines. Ann Intern Med 2005; 143:881-894.
Sources
For more information on treating pneumonia patients in the ED, contact:
- Richard Heath, MD, FACEP, Medical Director, Emergency Services, University of Pittsburgh Medical Center Braddock, 400 Holland Ave., Braddock, PA 15104-1599. Phone: (412) 636-5388.
- Donald M. Yealy, MD, Vice Chair, Emergency Medicine, University of Pittsburgh Medical Center; Professor, University of Pittsburgh School of Medicine. Phone: (412) 647-8295.
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