Community Acquired Pneumonia in the Emergency Department (ED) Emergency Department Nurses & Physicians Dr. Mark Cichon, Director; Bridget Gaughan, Manager Confidential: For Quality Improvement Purposes Only

“Time to first antibiotic dose for community acquired pneumonia (CAP) demonstrates statistically significant lower mortality among patients who receive early antibiotic therapy.”* *National Hospital Quality Measure Joint Commission, 2007; Centers for Medicare & Medicaid Services Current antibiotic guidelines for community-acquired pneumonia (CAP) patients are from consensus recommendations of the CDC as well as the American Infectious Disease and Thoracic Societies. EVIDENCE Confidential: For Quality Improvement Purposes Only

ED Patients with Symptoms of Community Acquired Pneumonia (CAP) Opportunity to improve –Timeliness of antibiotic administration –Selection of recommended antibiotic Confidential: For Quality Improvement Purposes Only

Desired outcome for patients admitted to the hospital for CAP –Improve mean time to treatment of CAP to 6 hours from time of arrival for 90% of patients* –Administer recommended antibiotic to 90% of patients * National Hospital Quality Measure Joint Commission, 2007; Centers for Medicare & Medicaid Services ED Patients with (CAP) Confidential: For Quality Improvement Purposes Only

Emergency Department CAP Solutions Implemented Created Step II triage –Provided nurse & tech earlier access to patients with complaints consistent with pneumonia Developed CAP standing order set –Nurse initiated patient orders prior to physician evaluation Opened ED observation unit –Expanded number of patient care areas Confidential: For Quality Improvement Purposes Only

Emergency Department CAP Solutions Implemented Access to antibiotics in ED –Stocked recommended antibiotics in Omnicell Educated staff –Use of Step II Triage & Standing Orders –Joint Commission & CMS Guidelines Provided individual performance data –Physicians & nurses received patient specific feedback regarding timeliness & appropriateness of antibiotic administration & selection Confidential: For Quality Improvement Purposes Only

Mean time to antibiotic administration improved from 79% to 89% overall 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 89%. A team of physicians and nurses are actively working to ensure that all patients with pneumonia receive initial antibiotics within 6 hours of arrival. August 2007 represents 4 patients, and no significant change in performance. Confidential: For Quality Improvement Purposes Only

Antibiotic selection consistent with guidelines improved from 92% to 97% 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 fallen in recent months. Confidential: For Quality Improvement Purposes Only

Next Steps Optimize existing processes –Enhance utilization of Step II triage for earlier activation of standing orders –Maximize staffing of ED Observation Unit to increase patient access to treatment areas New Process –Develop CAP Clinical Decision Unit guidelines and order sets to allow for ED observation admissions Confidential: For Quality Improvement Purposes Only