1. A Practice-Based Intervention to Improve Time-to-Antibiotic Administration in Pneumonia Suspects at Mulago Hospital, Kampala, Uganda Luke Davis, MD Pulmonary & Critical Care Medicine June 3, 2008

2. Overview Background Specific Aims Preliminary Studies Study Design Assessment & Implementation Strategy Measures Analysis Plan Human Subjects Questions

3. Mulago Hospital, Ugandan Ministry of Health, Kampala Mulago Hospital, Kampala, Uganda

4. Outcomes of respiratory illness at Mulago Hospital are poor In-hospital mortality among TB suspects 13% Initial medical evaluation takes ~24 hours ~10% community acquired pneumonia (CAP) suspects Antibiotic treatment standardized, but not timing of administration

5. Antibiotic timing and CAP Early antibiotic administration a/w improved CAP outcomes 1 High-intensity education at time of implementation of CAP QI a/w increased adherence to guidelines 2 Systematic QI research uncommon in resource- limited settings and of unknown efficacy 1 Arch Intern Med 2004 Mar 22;164(6):637-44. 2 Ann Intern Med. 2005 Dec 20;143(12):881-94.

6. Specific Aims To determine if a structured multimodal educational intervention can improve 1.Median time to antibiotic delivery 2.Hospital length of stay 3.Survival to discharge In patients with pneumonia at Mulago Hospital

7. Research Methods Study population –Adults with cough and pulmonary infiltrates –Medical casualty ward, Mulago Hospital Study design –Prospective non-experimental single-center cohort study

8. Preliminary Studies Epidemiology of pneumonia –10% of all admissions, 1% or more CAP Focus groups –Interests of nurses and doctors misaligned –Pharmacists not integrated into health care team

9. Assessment strategy Project proposed by a senior registrar PRECEDE – PROCEED theory for assessing –Quality of life = mortality, length of stay –Epidemiology = median time to antibiotic delivery –Education = knowledge of guidelines –Administration = support of thought-leaders Green & Kreuter, Health Program Planning, 4 th ed., NY, London: McGraw-Hill, 2005.

15. Implementation strategy 1.Measurement – Baseline & serial quantitative & qualitative outcomes 2.Education –Disseminate guidelines based on local & international literature, vetted by local thought leaders 3.Engagement of hospital leaders –Head of Medicine, Chief of Clinical Services, Hospital Director 4.Social marketing –Reminders and clinical decision support to doctors & nurses 5.Continuous Quality Improvement –Team of chief registrar, chief nurse, chief pharmacist Control Intervention

16. Measures Outcomes –Time-to-antibiotic delivery, length of stay, hospital mortality –Measured q1month x 24 months Predictors and covariates –Intervention, time since implemented –Clinical and seasonal covariates –Time-to-antibiotic delivery, health-care worker qualitative ratings Measurement “semi-blinded” –Nurse records time of arrival –Pharmacist records time antibiotic released from pharmacy

17. Analysis Plan Interrupted time series regression Power calculated with month 1 data for each intervention –Patients admitted with a respiratory complaint –Effect size from Δ intervention coefficient Process evaluation through significant covariates –p<0.05 for interventions, time-to-antibiotic delivery –Important effect sizes of other covariates for generating hypotheses

18. Human Subjects Risk to patients low, potential benefit is high Participation of health care workers implies consent to process evaluation Data on knowledge, attitudes, and beliefs will be de-identified.

19. Questions