1. Team Membership Stephanie Detterline, MD Mary E. Altier, MSN, RN Clinical Departments: Emergency Medical Services, General Medicine, Cardiac Services Hospital Departments: 6 Northeast, 3NESW, 2 NE, Emergency Department, Medical Records, Quality and Resource Management, Center for Clinical Effectiveness PNEUMONIA

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. ED Plan ED QI Project: “Pneumonia Core Measure: 4 hours to initial antibiotic.” ED special observation unit opened 9/2006 Creation of quarterly “dashboard” report card for ED highlighting measures that impact their practice. Fall 2006 Creation of individual ED physician performance reports. Fall 2006

5. Plan Appropriate antibiotics in ED Omnicell and as floorstock. Daily rounds on all in- patient pneumonia patients “No Flu” posters placed in patient rooms (October- December) Pneumovax/Influenza in- service to inpatient units Promotion of ambulatory walk-in clinics Smoking cessation counseling verbiage added to EPIC discharge navigator Participation in the UHC Core Measures Networking Collaborative 2006-2007 Participation in Patient Safety Fair: “In-patient Vaccinations” March 2007

6. Percent Core Measures Pneumonia Patients Composite Score Month UCL = 86.5 Mean = 52.2 LCL = 17.9 Apr 2005 (n=13) May 2005 (n=17) Jun 2005 (n=11) Jul 2005 (n=20) Aug 2005 (n=14)Sep 2005 (n=15) Oct 2005 (n=17) Nov 2005 (n=20)Dec 2005 (n=21) Jan 2006 (n=24) Feb 2006 (n=27)Mar 2006 (n=23) Apr 2006 (n=27) May 2006 (n=17) Jun 2006 (n=21) Jul 2006 (n=14) Aug 2006 (n=22)Sep 2006 (n=20) 20 40 60 80 100 Definition: Number of pneumonia patients receiving 100% of indicated care / all pneumonia patients Data Source: Original data extracted from LUMC charts by RNs. Analysis: LUMC performance is above the UHC median. Discharge form updated to include smoking cessation recommendations and increased nurse audits

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%, meeting the stretch goal. Stretch Goal is based on Senior Management Critical Success Factors for FY07

8. Definition: Collection of blood culture within the first 24 hours after arrival / pneumonia patients who were transferred to an intensive care unit within 24 hours of hospital arrival. Data Source: Original data extracted from LUMC charts by RNs. Analysis: LUMC performance is consistent at 93%. Stretch Goal is based on Senior Management Critical Success Factors for FY07 Percent Core Measures Pneumonia Patients Receiving Blood Cultures Within 24 Hours for those Admitted to the ICU Within 24 Hours of Hospital Arrival Month UCL = 131.2 Mean = 93.2 LCL = 55.2 Jul 2005 (n=4) Aug 2005 (n=2)Sep 2005 (n=4) Oct 2005 (n=3) Nov 2005 (n=4)Dec 2005 (n=3) Jan 2006 (n=8) Feb 2006 (n=3) Mar 2006 (n=1) Apr 2006 (n=7) May 2006 (n=5) Jun 2006 (n=4) Jul 2006 (n=3) Aug 2006 (n=4)Sep 2006 (n=4) 20 40 60 80 100 120 140 160

9. Definition: Collection of blood cultures in the emergency department prior to first dose of antibiotic / pneumonia patients who received blood cultures and antibiotics after arrival. Data Source: Original data extracted from LUMC charts by RNs. Analysis: LUMC performance is consistent at 92%. Percent Core Measures Pneumonia Patients Receiving Blood Cultures in the Emergency Dept Before First Antibiotic Month UCL = 112.5 Mean = 91.9 LCL = 71.4 Jul 2005 (n=16) Aug 2005 (n=13)Sep 2005 (n=14) Oct 2005 (n=16) Nov 2005 (n=16)Dec 2005 (n=19) Jan 2006 (n=20) Feb 2006 (n=22)Mar 2006 (n=16) Apr 2006 (n=20) May 2006 (n=12) Jun 2006 (n=12) Jul 2006 (n=11) Aug 2006 (n=15)Sep 2006 (n=14) 70 80 90 100 110

10. 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 consistent at 66%. A team of physicians and nurses are actively working to ensure that all patients with pneumonia receive initial antibiotics within 4 hours of arrival. Stretch Goal is based on Senior Management Critical Success Factors for FY07 Percent Core Measures Pneumonia Patients Receiving Initial Antibiotic within 4 Hours of Hospital Arrival Month UCL = 105.6 Mean = 66.1 LCL = 26.6 Stretch Goal = 80% Apr 2005 (n=10) May 2005 (n=10) Jun 2005 (n=9) Jul 2005 (n=15) Aug 2005 (n=10) Sep 2005 (n=8) Oct 2005 (n=11) Nov 2005 (n=16)Dec 2005 (n=17) Jan 2006 (n=17) Feb 2006 (n=15)Mar 2006 (n=16) Apr 2006 (n=19) May 2006 (n=9) Jun 2006 (n=13) Jul 2006 (n=10) Aug 2006 (n=13)Sep 2006 (n=15) 20 40 60 80 100 120

11. 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. Analysis: LUMC performance is consistently at 92%. Stretch Goal is based on Senior Management Critical Success Factors for FY07 Percent Core Measures Pneumonia non-ICU Patients Receiving Initial Antibiotic Selection Consistent with Current Guidelines Month UCL = 120.8 Mean = 91.7 LCL = 62.6 Stretch Goal = 95% Apr 2005 (n=7) May 2005 (n=7) Jun 2005 (n=6) Jul 2005 (n=8) Aug 2005 (n=7)Sep 2005 (n=5) Oct 2005 (n=10) Nov 2005 (n=7)Dec 2005 (n=8) Jan 2006 (n=11) Feb 2006 (n=12)Mar 2006 (n=14) Apr 2006 (n=10) May 2006 (n=6) Jun 2006 (n=9) Jul 2006 (n=3) Aug 2006 (n=5) Sep 2006 (n=10) 40 60 80 100 120 140

12. 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: LUMC performance is at 83%. Interventions have been implemented into the electronic medical record to ensure all patients receive pneumococcal vaccination when appropriate. Stretch Goal is based on Senior Management Critical Success Factors for FY07 Percent Core Measures Pneumonia Patients Receiving Pneumococcal Vaccination Month UCL = 119.5 Mean = 82.5 LCL = 45.4 Stretch Goal = 90% Apr 2005 (n=8) May 2005 (n=11) Jun 2005 (n=7) Jul 2005 (n=7) Aug 2005 (n=10) Sep 2005 (n=5) Oct 2005 (n=7) Nov 2005 (n=6) Dec 2005 (n=11) Jan 2006 (n=11) Feb 2006 (n=16)Mar 2006 (n=13) Apr 2006 (n=15) May 2006 (n=11) Jun 2006 (n=8) Jul 2006 (n=7) Aug 2006 (n=9)Sep 2006 (n=9) 40 60 80 100 120

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 inconsistent but recently appears promising. Since April 2005, 69% of eligible pneumonia patients who smoke have received counseling. Stretch Goal is based on Senior Management Critical Success Factors for FY07 Discharge form updated to include smoking cessation recommendations with increased nurse audits Apr 2005 (n=3) May 2005 (n=2) Jun 2005 (n=4) Jul 2005 (n=5) Aug 2005 (n=2) Sep 2005 (n=2) Oct 2005 (n=2) Nov 2005 (n=3) Dec 2005 (n=2) Jan 2006 (n=9) Feb 2006 (n=5) Mar 2006 (n=3) Apr 2006 (n=2) May 2006 (n=5) Jun 2006 (n=4) Jul 2006 (n=2) Aug 2006 (n=6) Sep 2006 (n=4) 0 20 40 60 80 100 120 140 160

14. Next Steps Ed initiative: use of ancillary room in ED waiting room to obtain blood cultures and send patient for chest x-ray. Presentation at University Healthsystem Consortium as “Top Performer: Pneumonia Core Measure” May 2007