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 Appropriate antibiotics in ED Omnicell and as floor stock Daily monitoring of all inpatient pneumonia patients “No Flu” posters to be placed in patient rooms (October- December) Pneumovax/ Influenza in-services to inpatient units Pneumovax/ Influenza screening orders added to Epic discharge instructions Participation in Patient Safety Fair Confidential: For Quality Improvement Purposes Only

6. 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 orders as part of the discharge summary instructions in Epic Create individual nurse specific reports for vaccine screening and administration on a quarterly basis Confidential: For Quality Improvement Purposes Only

7. 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

8. 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%. ED Standing Orders based on symptoms and age to allow RN to deliver specific antibiotics, draw blood culture, and order chest x-ray Percent Pneumonia Patients Receiving Blood Cultures in the Emergency Dept Before First Antibiotic Month UCL = 111.0 Mean = 93% LCL = 75.1 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=16) Sep 2006 (n=16) Oct 2006 (n=15) Nov 2006 (n=14) Dec 2006 (n=20) 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) 0 20 40 60 80 100 120 ED Standing Orders based on guidelines that allow RN to order chest x-ray, blood culture & deliver first dose antibiotic Confidential: For Quality Improvement Purposes Only

9. 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 now 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. Percent Pneumonia Patients Receiving Initial Antibiotic within 6 Hours of Hospital Arrival Month UCL = 111.2 Mean = 79% LCL = 47.7 UCL = 111.8 Mean = 89% LCL = 66.1 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=14) Sep 2006 (n=19) Oct 2006 (n=17) Nov 2006 (n=13) Dec 2006 (n=13) 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) 0 20 40 60 80 100 120 140 ED Standing Orders based on guidelines that allow RN to order chest x-ray, blood culture & deliver first dose antibiotic Confidential: For Quality Improvement Purposes Only

10. 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. Percent Pneumonia non-ICU Patients Receiving Initial Antibiotic Selection Consistent with Current Guidelines Month UCL = 118.5 Mean = 92% LCL = 65.2 UCL = 115.8 Mean = 97% LCL = 78.3 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=6) Sep 2006 (n=11) Oct 2006 (n=10) Nov 2006 (n=5) Dec 2006 (n=8) 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) 0 20 40 60 80 100 120 140 ED Standing Orders based on guidelines that allow RN to order chest x-ray, blood culture & deliver first dose antibiotic Confidential: For Quality Improvement Purposes Only

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 dropped significantly in November 2007, but recovered in 2008. This timing correlates with nursing documentation go-live and transition in project related quality coaching. Percent Pneumonia Patients Receiving Pneumococcal Vaccination Month UCL = 112.9 Mean = 82% LCL = 51.8 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=11) Oct 2006 (n=17) Nov 2006 (n=10) Dec 2006 (n=16) 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) 0 20 40 60 80 100 120 Nursing Go-Live Pneumonia team transition Confidential: For Quality Improvement Purposes Only

13. 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: LUMC performance was at 76% for the 2006 and 2007 flu seasons, but dropped to 58% for the 2008 flu season. Nursing leaders are actively working on strategies to ensure the provision of influenza vaccination to all appropriate patients. Percent Pneumonia Patients Receiving Influenza Vaccination Month UCL = 97.1 Mean = 67% LCL = 36.8 Jan 2006 (n=16) Feb 2006 (n=19) Nov 2006 (n=19) Dec 2006 (n=19) 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) 0 20 40 60 80 100 Nursing Go-Live Pneumonia team transition Confidential: For Quality Improvement Purposes Only