Study prompts overhaul of COPD/pneumonia care
Sluggish antibiotic administration targeted
Lag time in antibiotic administration has a cascading effect. Patients remain sicker, longer, which leads to longer length of stays (LOS) and higher readmission rates. This was a key reason behind an Alaska hospital's high LOS and readmission rate for pneumonia and chronic obstructive pulmonary disease (COPD) patients.
Central Peninsula General Hospital in Soldotna, AK, discovered it was among seven rural Alaska hospitals that had a slow rate of antibiotic administration for pneumonia and COPD patients presenting to the emergency department. A 1994 study by Pro-West, the state Peer Review Organization (PRO), showed that only 22.8% of patients at the seven hospitals received antibiotics within two hours after presenting to the emergency department. A total of 56.9% of patients received antibiotics within four hours, and 71.5% received antibiotics within six hours. The median time for administering antibiotics at the hospitals was 3.4 hours.
Meanwhile, the LOS at Central Peninsula averaged 5.5 days and readmission rates were high at 11.2%the hospital, says Terry Martin, RN, care coordinator and case manager at the 54-bed hospital.
The information in the PRO study gave Martin and others direction to turn those numbers around. An internal task force at Central Peninsula was created to root out causes for longer lengths of stay and higher readmission. The task force's work has started paying dividends. Readmission rates for pneumonia and COPD have dropped to 7.2%, and the average LOS has gone down to 4.1 days, Martin says.
Indicators spotlighted problems
Pro-West reviewed care of pneumonia and COPD patients as part of its contract with the Baltimore-based Health Care Financing Administration (HCFA), to monitor quality of care for Medicare beneficiaries, says Mary Ellen Gordian, MD, principal clinical coordinator for Pro-West Alaska in Anchorage.
A literature review helped Pro-West determine important indicators for pneumonia and COPD treatment, such as:
* check of health conditions prior to admission;
* medications taken on admission;
* tests ordered and results;
* length of time until the patient receives the first dose of antibiotics.
The PRO developed a list of Medicare patients who had been admitted for pneumonia over a period of one year and developed an abstraction tool with which to extrapolate care data (See pneumonia data collection sheet, insert.)
Nurse clinicians from hospitals throughout Alaska were asked to review charts using the abstraction tool, which asked questions such as what antibiotics were used and what diagnostic tests were done, Gordian says. Pro-West used the results to develop a report pinpointing problems, she says.
Team pinpoints problem areas
After the study's release, Central Peninsula assembled a multidisciplinary team called the Pulmonary Task Force. It included the respiratory therapy manager, a pharmacist, a discharge planner, a staff nurse, an emergency department nurse, an intensive care unit nurse, two care coordinators, a quality management employee, a utilization reviewer, and the director of nursing.
The task force not only pinpointed the problem with antibiotic administration, it also identified two other problems:
* Physician practice patterns and resource utilization varied despite the existence of care pathways because physicians did not always follow the paths or note variations.
* Lack of continuity in patient education among health care providers meant patients did not always receive the best post-discharge care instructions.
The task force first targeted variations in physician practice patterns and resource utilization. They discovered physicians weren't following the pathways Martin created, she says. While physicians liked the idea of pathways, they were created by nurses so physicians didn't use them, she says.
To demonstrate that the pathways were relevant to physicians, as well as nurses, the team listed costs of care for each physician's patients followed with a peer comparison. (See comparison of resource utilization, average cost per case, this page.)
The order that never ends
In Alaska, where managed care remains a new concept, the physicians had never had any type of peer analysis or profile, Martin says. The results showed a wide variation in the way resources were used and how physicians practiced.
For example, one physician questioned why his cardiopulmonary charges were higher than his peers. "It turned out that when he wrote an order for oxygen, he never discontinued it," Martin says. "The patient was charged for oxygen for the entire hospital stay, whether it was needed or not." Now, the physician assesses his patients' oxygen needs daily and orders accordingly. His patients' oxygen charges have decreased significantly, she says.
In tackling improvements to antibiotic administration, the task force set a goal of administering antibiotics within two hours. The team first examined the treatment process and saw that it broke down in several places including how the order was sent to the pharmacy and how the nurses prioritized antibiotic administration. For example, the pharmacy often would send antibiotics for pneumonia and COPD patients along with intravenous medications, and they were easily lost, Martin says.
Fail-safe procedures were added to the process of medication ordering and administration to ensure antibiotics were ordered, dispensed, and administered on time, Martin says. During the new process:
* The ward clerk or ED technician alerts the nurse that an antibiotic order has been placed.
* The ward clerk makes sure the pharmacy receives the order immediately.
* The pharmacy clerk alerts the ED nurse when the antibiotic is ready and sends it over.
As a result, about 95% of antibiotics are now administered within two hours of presenting, Martin says.
The changes have had a positive financial impact, too. The hospital lost $249,500 in 1994 on pneumonia and COPD patients, Martin says. It lost only $90,000 in 1995 and expects to break even this year. *
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