'Clock' form scores 100% compliance for pneumonia
Nurses use clock logo for timely antibiotics
More than 1.2 million Americans were hospitalized for pneumonia in 2006, with 71% of those cases admitted through the ED, according to a new analysis using data from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project.
At Inova Alexandria (VA) Hospital, the ED Clinical Practice Council, which consists of physician, nursing, and quality staff, wanted to improve compliance with The Joint Commission's requirement to give antibiotics within four hours of arrival for patients who are diagnosed with pneumonia. In previous years, compliance hovered at 85%.
A form was created with a picture of a clock, printed on bright-yellow paper, and placed on the top of the patient's chart. "We literally sketched it out on paper, with input from our Council," said Joanne Scarlato, RN, management coordinator for the ED. A decision was made to use a digital clock, since it was easier for nurses to record the time. (See the ED's form.) Triage criteria and protocols were also developed.
Pneumonia standing orders are now used for patients with two or more of these symptoms:
- temperature of 100.5° or higher;
- cough;
- dyspnea/shortness of breath;
- noncardiac chest pain;
- hypoxia (pulse oximetry less than 94%);
- altered breath sounds;
- tachycardia (heart rate over 90).
"If a patient is short of breath and coughing and they arrive at 2 p.m., you know that you have only until 6 p.m. to treat them," said Scarlato. The ED has been at 100% compliance for more a year now, she reports.
After the patient's arrival time is documented on the clock form, ED nurses notify the charge nurse and obtain a chest X-ray, complete blood count, comprehensive metabolic panel, blood cultures, and urinalysis. If the chest X-ray is positive, the patient receives antibiotics within four hours.
In the beginning, though, some ED nurses thought the new protocol would mean additional work. "There are always questions and concerns when you change anything. Our staff thought this process was not of high importance," says Jessica Rocca, RN, an ED nurse who helped educate staff on the new process. "But once they saw the results, they realized the additional steps that were taken improved patient care."
The picture of the clock on the form "really does make a big difference," says Rocca. "Nurses know if the patient has two of any of these symptoms, they qualify even if you don't think they have pneumonia."
For example, a patient might report a racing heart and chest pain, and will therefore get an electrocardiogram (EKG), but this patient also will qualify for the pneumonia protocol. In addition, the protocol catches pneumonia patients during the summer when they might be more easily overlooked. "For every 100 patients on the protocol in July, we may get one who actually has pneumonia," Scarlato says.
Documentation was another challenge, as with a patient who was not given an antibiotic for a good reason: He already had taken it before coming to the ED. "He was admitted, but unfortunately the record did not indicate that the patient took their own antibiotic," said Scarlato. "This was recorded in the statistics as being noncompliant. The champions of this pneumonia process took steps to ensure a similar situation did not occur again."
More than 1.2 million Americans were hospitalized for pneumonia in 2006, with 71% of those cases admitted through the ED, according to a new analysis using data from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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