PNEUMONIA Team Membership: Susan A . Tuzik, MS, RN Rose Lach, Administrative Director Clinical Departments: Emergency Medical Services, General Medicine, Cardiac Services Hospital Departments: 6 Northeast, 3NESW, 2 NE, Emergency Department, Medical Records, Quality & Resource Management, Center for Clinical Effectiveness Confidential: For Quality Improvement Purposes Only

Forces of Magnetism Force 6: Quality of Care Force 7: Quality Improvement Force 9: Autonomy Force 13: Interdisciplinary Relationships Confidential: For Quality Improvement Purposes Only

Room for Improvement To increase the rates for those quality measures specific to the Pneumonia Core measure: Antibiotic timing Appropriate Antibiotic Administered Adult Smoking Cessation Counseling Blood Culture Collection Pneumococcal Vaccination: > 65 years of age Influenza Vaccination: > 50 years of age Confidential: For Quality Improvement Purposes Only

Goals Initial antibiotics administered within 6 hours of arrival at hospital Appropriate antibiotic administered Blood cultures collected prior to initial antibiotic dose 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 Confidential: For Quality Improvement Purposes Only

Plan System-wide influenza campaign Oct-Feb with posters placed in general population and all in-patient rooms. Pneumovax/ Influenza in-services to inpatient units. Monthly ED “dashboard” reports with timing/outliers provided to all staff. Provide bi-weekly compliance reports to managers. Provide performance data to Senior Management, Leapfrog Committee, Pneumonia Task Force & all nursing units. EPIC pneumonia & influenza vaccine screening on patient data base. If screen positive, vaccination orders placed by nurse. Confidential: For Quality Improvement Purposes Only

Accomplishments Pneumonia Core Measure presentations provided to various nursing units as needed or requested Presentations at the nurse manager’s meetings Ongoing communication with nurse managers and nurses regarding outliers Developing nurse specific outlier reports for ongoing education and awareness Confidential: For Quality Improvement Purposes Only

Pneumonia Patients Receiving Blood Cultures Within 24 Hours Percent Pneumonia Patients Receiving Blood Cultures Within 24 Hours for those Admitted to the ICU Within 24 Hours of Hospital Arrival Month UCL = 122.6 Mean = 95.3 LCL = 68.1 Jan 2007 (n=5) Feb 2007 (n=5) Mar 2007 (n=8) Apr 2007 (n=7) May 2007 (n=2) Jun 2007 (n=5) Jul 2007 (n=8) Aug 2007 (n=5) Sep 2007 (n=7) Oct 2007 (n=6) Nov 2007 (n=4) Dec 2007 (n=5) Jan 2008 (n=8) Feb 2008 (n=5) Mar 2008 (n=5) Apr 2008 (n=5) May 2008 (n=4) Jun 2008 (n=7) Jul 2008 (n=2) Aug 2008 (n=5) Sep 2008 (n=8) Oct 2008 (n=3) Nov 2008 (n=5) Dec 2008 (n=5) 20 40 60 80 100 120 140 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 has been 100% for this measure since June 2008.

Pneumonia Patients Receiving Blood Cultures in the Percent Pneumonia Patients Receiving Blood Cultures in the Emergency Dept Before First Antibiotic Month UCL = 110.8 Mean = 93.2 LCL = 75.7 Jan 2007 (n=26) Feb 2007 (n=15) Mar 2007 (n=34) Apr 2007 (n=19) May 2007 (n=17) Jun 2007 (n=11) Jul 2007 (n=19) Aug 2007 (n=7) Sep 2007 (n=30) Oct 2007 (n=13) Nov 2007 (n=18) Dec 2007 (n=16) Jan 2008 (n=23) Feb 2008 (n=18) Mar 2008 (n=28) Apr 2008 (n=16) May 2008 (n=16) Jun 2008 (n=19) Jul 2008 (n=12) Aug 2008 (n=12) Sep 2008 (n=20) Oct 2008 (n=16) Nov 2008 (n=21) Dec 2008 (n=18) 20 40 60 80 100 120 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 93%.

Pneumonia Patients Receiving Initial Antibiotic Percent Pneumonia Patients Receiving Initial Antibiotic within 6 Hours of Hospital Arrival Month UCL = 111.8 Mean = 87.2 LCL = 62.7 Jan 2007 (n=24) Feb 2007 (n=14) Mar 2007 (n=25) Apr 2007 (n=16) May 2007 (n=12) Jun 2007 (n=9) Jul 2007 (n=18) Aug 2007 (n=4) Sep 2007 (n=22) Oct 2007 (n=15) Nov 2007 (n=14) Dec 2007 (n=19) Jan 2008 (n=18) Feb 2008 (n=17) Mar 2008 (n=27) Apr 2008 (n=16) May 2008 (n=20) Jun 2008 (n=16) Jul 2008 (n=10) Aug 2008 (n=14) Sep 2008 (n=14) Oct 2008 (n=17) Nov 2008 (n=19) Dec 2008 (n=20) 20 40 60 80 100 120 140 Definition: Pneumonia patients who receive initial antibiotic within 6 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 87%. A team of physicians and nurses are actively working to ensure that all patients with pneumonia receive initial antibiotics within 6 hours of arrival.

Pneumonia non-ICU Patients Receiving Initial Antibiotic Selection Percent Pneumonia non-ICU Patients Receiving Initial Antibiotic Selection Consistent with Current Guidelines Month UCL = 118.2 Mean = 95.9 LCL = 73.6 Jan 2007 (n=18) Feb 2007 (n=10) Mar 2007 (n=17) Apr 2007 (n=7) May 2007 (n=6) Jun 2007 (n=5) Jul 2007 (n=5) Aug 2007 (n=1) Sep 2007 (n=9) Oct 2007 (n=6) Nov 2007 (n=6) Dec 2007 (n=9) Jan 2008 (n=4) Feb 2008 (n=5) Mar 2008 (n=12) Apr 2008 (n=9) May 2008 (n=6) Jun 2008 (n=4) Jul 2008 (n=6) Aug 2008 (n=3) Sep 2008 (n=4) Oct 2008 (n=8) Nov 2008 (n=5) Dec 2008 (n=6) 20 40 60 80 100 120 140 160 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 improved significantly, following process changes in the emergency department in January 2007, but has dropped to 90% in 2008.

Pneumonia Patients Receiving Pneumococcal Vaccination UCL = 112.4 Mean = 80.0 120 100 80 60 LCL = 47.6 Percent 40 Nursing Go-Live Pneumonia team transition Nursing Go-Live Pneumonia team transition 20 Jan 2007 (n=24) Feb 2007 (n=16) Mar 2007 (n=24) Apr 2007 (n=16) May 2007 (n=12) Jun 2007 (n=8) Jul 2007 (n=16) Aug 2007 (n=6) Sep 2007 (n=20) Oct 2007 (n=11) Nov 2007 (n=15) Dec 2007 (n=17) Jan 2008 (n=13) Feb 2008 (n=9) Mar 2008 (n=28) Apr 2008 (n=10) May 2008 (n=15) Jun 2008 (n=13) Jul 2008 (n=6) Aug 2008 (n=10) Sep 2008 (n=8) Oct 2008 (n=12) Nov 2008 (n=10) Dec 2008 (n=11) Month 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: In 2009, this process has moved to the admission side of the inpatient stay. Patients are being screened upon admission by nurses who then are able to provide the indicated vaccinations. The discharge process serves as a double check to this new process.

Pneumonia Patients Receiving Influenza Vaccination Percent Pneumonia Patients Receiving Influenza Vaccination Month UCL = 96.8 Mean = 66.7 100 80 Nursing Go-Live Pneumonia team transition Nursing Go-Live Pneumonia team transition 60 LCL = 36.6 40 20 Jan 2007 (n=36) Feb 2007 (n=17) Oct 2007 (n=16) Nov 2007 (n=22) Dec 2007 (n=23) Jan 2008 (n=22) Feb 2008 (n=16) Mar 2008 (n=38) Oct 2008 (n=19) Nov 2008 (n=17) Dec 2008 (n=17) Definition: Pneumonia patients age 50 and older who were screened for influenza vaccine status and were administered the vaccine prior to discharge, if indicated. Data Source: Original data extracted from LUMC charts by RNs. Analysis: In 2009, this process has moved to the admission side of the inpatient stay. Patients are being screened upon admission by nurses who then are able to provide the indicated vaccinations. The discharge process serves as a double check to this new process.

Smokers Receiving Smoking Cessation Advice for Pneumonia Patients Percent Smokers Receiving Smoking Cessation Advice for Pneumonia Patients Month UCL = 124.2 Mean = 95.0 LCL = 65.8 Jan 2007 (n=8) Feb 2007 (n=5) Mar 2007 (n=9) Apr 2007 (n=6) May 2007 (n=4) Jun 2007 (n=1) Jul 2007 (n=9) Aug 2007 (n=7) Sep 2007 (n=7) Oct 2007 (n=4) Nov 2007 (n=4) Dec 2007 (n=7) Jan 2008 (n=5) Feb 2008 (n=7) Mar 2008 (n=5) Apr 2008 (n=4) May 2008 (n=6) Jun 2008 (n=4) Jul 2008 (n=4) Aug 2008 (n=1) Sep 2008 (n=4) Oct 2008 (n=4) Nov 2008 (n=2) Dec 2008 (n=3) 20 40 60 80 100 120 140 160 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: Smoking cessation advice has decreased significantly at the end of 2008.

Next Steps Continue to provide in-services for inpatient units to increase compliance of Pneumococcal and Influenza vaccination screening and administration Continue to monitor effectiveness of vaccination screening on admission data base. Add reminder to complete vaccination screening on Patient Care Summary. Continue individual nurse specific reports for vaccine screening and administration on a monthly basis. Add smoking cessation counseling to patient transfer form. Confidential: For Quality Improvement Purposes Only