1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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.

8. 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%.

9. 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.

10. 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.

11. 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.

12. 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.

13. 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.

14. 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