PNEUMONIAPNEUMONIA

Team Membership Salma Mohsin, MD Mary E. Altier, MSN, RN

Clinical Departments: Emergency Medical Services, General MedicineHospital Departments: 6 Northeast, 3NESW, 2 NE, Emergency Department, Medical Records, Quality and Resource Management, Center for Clinical Effectiveness

Opportunity for ImprovementOpportunity for Improvement

To improve the rates of quality measures specific to the Pneumonia Core measure:

• Antibiotic Timing• Appropriate Antibiotic Administered• Blood Culture Collection • Oxygen Level Assessment• Pneumococcal Vaccination: > 65 years • Influenza Vaccination: > 50 years• Adult Smoking Cessation Counseling

GoalsGoals• Initial antibiotic administered

within 4 hours of arrival at hospital

• Appropriate antibiotic administered

• Blood cultures collected prior to initial antibiotic dose

• Oxygen level assessed within initial 24 hours of arrival

• 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

PlanPlan• Improve initial antibiotic dose timing by providing appropriate antibiotics

in Omni-Cell in ED and as floor stock in hospital

• Meet with resident staff regarding ordering medications as “STAT” or ‘NOW” for initial therapy

• Improve blood cultures drawn prior to antibiotic administration timing

• Revise Pneumococcal and Influenza Standing Order Policy after review of CDC recommendations and estimation of influenza vaccine supply is determined.

• Re-education of hospital units/departments

Plan • Influenza Vaccination posters placed in patient rooms, general population

areas and all Out-patient sites. (October-February)

• Vaccination audit project for proper screening for 2 NEWS, 3 NEWS, 6NE, 7SW. Analyze and provide unit and nurse specific performance data to managers

• Provide monthly outlier reports to stakeholders to identify trends and opportunities for improvement

• Provide monthly reports to units with department specific results

• Provide overall performance data to the Pneumonia Task Force, General Medicine Service Line, and National Hospital Quality Measures Committee

Next StepsNext Steps• Revise Standing Pneumonia Orders. Transition from CAP to general

pneumonia• Nursing Home Patient Initiative: Floors/ICU• ED QI Project: On-going• Participation on Stroke Team: Disease Specific Certification through

JCAHO. Pneumovax Screening required. • Standard verbiage for Smoking Cessation on discharge forms• Smoking Task Force Reconvene• Pneumovax/Influenza In-service to inpatient units• Participation in the UHC Core Measures Networking Collaborative

2005-2006

Definition: Pneumonia patients who had an assessment of arterial oxygenation by arterial blood gas measurement or pulse oximetry within 24 hours prior to or after arrival at the hospital / All pneumonia patients.

Data Source: Original data extracted from LUMC charts by RNs.

Analysis: LUMC pneumonia patients receive oxygen assessment as a standard of practice. LUMC performance is stable with an average of 100%.

Per

cent

National Hospital Quality MeasuresOxygen Assessment for Pneumonia Patients

* Preliminary data for quality improvement purposes onlyMonth

p chart

Jan-

04 (n

=43)

Feb-0

4 (n

=31)

Mar

-04

(n=2

8)

Apr-0

4 (n

=24)

May

-04

(n=3

5)

Jun-

04 (n

=19)

Jul-0

4 (n

=15)

Aug-0

4 (n

=11)

Sep-0

4 (n

=19)

Oct-0

4 (n

=23)

Nov-0

4 (n

=20)

Dec-0

4 (n

=12)

Jan-

05 (n

=37)

Feb-0

5 (n

=24)

Mar

-05

(n=1

6)

Apr-0

5 (n

=13)

May

-05

(n=1

7)

Jun-

05 (n

=11)

Jul-0

5 (n

=19)

Aug-0

5 (n

=14)

Sep-0

5 (n

=15)

*Oct

-05

(n=1

7)

*Nov

-05

(n=1

9)

*Dec

-05

(n=2

0)

*Jan

-06

(n=2

2)

99.990

99.995

100.000

100.005

100.010

Definition: Collection of blood culture prior to first dose of antibiotic / pneumonia patients who received blood cultures after arrival, and antibiotics within 36 hours after arrival.

Data Source: Original data extracted from LUMC charts by RNs.

Analysis: LUMC performance is stable with an average of 84%. Recent performance appears promising.

Per

cent

National Hospital Quality MeasuresBlood Culture Drawn Prior to Initial Antibiotic for Pneumonia Patients

* Preliminary data for quality improvement purposes onlyMonth

p chart

Jan-

04 (n

=39)

Feb-0

4 (n

=15)

Mar

-04

(n=1

8)

Apr-0

4 (n

=19)

May

-04

(n=2

5)

Jun-

04 (n

=14)

Jul-0

4 (n

=12)

Aug-0

4 (n

=9)

Sep-0

4 (n

=18)

Oct-0

4 (n

=19)

Nov-0

4 (n

=15)

Dec-0

4 (n

=11)

Jan-

05 (n

=32)

Feb-0

5 (n

=21)

Mar

-05

(n=1

6)

Apr-0

5 (n

=13)

May

-05

(n=1

4)

Jun-

05 (n

=8)

Jul-0

5 (n

=16)

Aug-0

5 (n

=13)

Sep-0

5 (n

=14)

*Oct

-05

(n=1

6)

*Nov

-05

(n=1

6)

*Dec

-05

(n=1

7)

*Jan

-06

(n=1

8)

50

60

70

80

90

100

110

120

UCL = 110.54

Mean = 83.88

LCL = 57.22

Definition: Pneumonia patients who receive initial antibiotic within 4 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 at 66%. A temporary improvement occurred from February to September 2005. A team of physicians and nurses are actively working to ensure that all patients with pneumonia receive initial antibiotics within 4 hours of arrival.

Per

cen

tNational Hospital Quality Measures

Pneumonia Patients Receiving Initial Antibiotics Within 4 Hours of Hospital Arrival

* Preliminary data for quality improvement purposes onlyMonth

p chart

Jan-

04 (n

=41)

Feb-0

4 (n

=23)

Mar

-04

(n=2

1)

Apr-0

4 (n

=20)

May

-04

(n=2

9)

Jun-

04 (n

=17)

Jul-0

4 (n

=11)

Aug-0

4 (n

=5)

Sep-0

4 (n

=17)

Oct-0

4 (n

=16)

Nov-0

4 (n

=14)

Dec-0

4 (n

=9)

Jan-

05 (n

=30)

Feb-0

5 (n

=16)

Mar

-05

(n=1

0)

Apr-0

5 (n

=10)

May

-05

(n=9

)

Jun-

05 (n

=9)

Jul-0

5 (n

=15)

Aug-0

5 (n

=10)

Sep-0

5 (n

=8)

*Oct

-05

(n=1

1)

*Nov

-05

(n=1

6)

*Dec

-05

(n=1

7)

*Jan

-06

(n=1

5)

0

20

40

60

80

100

120

UCL = 101.88

Mean = 66.42

LCL = 30.95

Engagement of ED leadership

Per

cen

tNational Hospital Quality Measures

Pneumonia Patients Receiving Initial Antibiotics Within 4 Hours of Hospital Arrival

* Preliminary data for quality improvement purposes onlyMonth

p chart

Jan-

04 (n

=41)

Feb-0

4 (n

=23)

Mar

-04

(n=2

1)

Apr-0

4 (n

=20)

May

-04

(n=2

9)

Jun-

04 (n

=17)

Jul-0

4 (n

=11)

Aug-0

4 (n

=5)

Sep-0

4 (n

=17)

Oct-0

4 (n

=16)

Nov-0

4 (n

=14)

Dec-0

4 (n

=9)

Jan-

05 (n

=30)

Feb-0

5 (n

=16)

Mar

-05

(n=1

0)

Apr-0

5 (n

=10)

May

-05

(n=9

)

Jun-

05 (n

=9)

Jul-0

5 (n

=15)

Aug-0

5 (n

=10)

Sep-0

5 (n

=8)

*Oct

-05

(n=1

1)

*Nov

-05

(n=1

6)

*Dec

-05

(n=1

7)

*Jan

-06

(n=1

5)

0

20

40

60

80

100

120

UCL = 101.88

Mean = 66.42

LCL = 30.95

Definition: Immunocompetent 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 is at 80%.

Per

cent

National Hospital Quality MeasuresAntibiotic Selection for All Pneumonia Patients

* Preliminary data for quality improvement purposes onlyMonth

p chart

Jul-0

4 (n

=12)

Aug-0

4 (n

=4)

Sep-0

4 (n

=14)

Oct-0

4 (n

=13)

Nov-0

4 (n

=16)

Dec-0

4 (n

=7)

Jan-

05 (n

=25)

Feb-0

5 (n

=16)

Mar

-05

(n=7

)

Apr-0

5 (n

=9)

May

-05

(n=8

)

Jun-

05 (n

=6)

Jul-0

5 (n

=10)

Aug-0

5 (n

=7)

Sep-0

5 (n

=5)

*Oct

-05

(n=1

2)

*Nov

-05

(n=9

)

*Dec

-05

(n=8

)

*Jan

-06

(n=1

3)

20

40

60

80

100

120

140

UCL = 116.92

Mean = 80.10

LCL = 43.27

Measure specification change to address unique needs

of healthcare associated pneumonia patients

Per

cent

National Hospital Quality MeasuresAntibiotic Selection for All Pneumonia Patients

* Preliminary data for quality improvement purposes onlyMonth

p chart

Jul-0

4 (n

=12)

Aug-0

4 (n

=4)

Sep-0

4 (n

=14)

Oct-0

4 (n

=13)

Nov-0

4 (n

=16)

Dec-0

4 (n

=7)

Jan-

05 (n

=25)

Feb-0

5 (n

=16)

Mar

-05

(n=7

)

Apr-0

5 (n

=9)

May

-05

(n=8

)

Jun-

05 (n

=6)

Jul-0

5 (n

=10)

Aug-0

5 (n

=7)

Sep-0

5 (n

=5)

*Oct

-05

(n=1

2)

*Nov

-05

(n=9

)

*Dec

-05

(n=8

)

*Jan

-06

(n=1

3)

20

40

60

80

100

120

140

UCL = 116.92

Mean = 80.10

LCL = 43.27

Measure specification change to address unique needs

of healthcare associated pneumonia patients

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: There was a significant improvement with the implementation of standing orders for vaccine administration. Performance continues at 69%.

Per

cent

National Hospital Quality MeasuresPneumonia Vaccine for Pneumonia Patients

* Preliminary data for quality improvement purposes onlyMonth

p chart

Jan-

04 (n

=26)

Feb-0

4 (n

=7)

Mar

-04

(n=8

)

Apr-0

4 (n

=6)

May

-04

(n=1

3)

Jun-

04 (n

=9)

Jul-0

4 (n

=10)

Aug-0

4 (n

=4)

Sep-0

4 (n

=14)

Oct-0

4 (n

=10)

Nov-0

4 (n

=12)

Dec-0

4 (n

=6)

Jan-

05 (n

=25)

Feb-0

5 (n

=13)

Mar

-05

(n=6

)

Apr-0

5 (n

=8)

May

-05

(n=1

1)

Jun-

05 (n

=7)

Sep-0

5 (n

=5)

*Oct

-05

(n=7

)

*Nov

-05

(n=7

)

*Dec

-05

(n=1

0)

*Jan

-06

(n=9

)

20

40

60

80

100

120

UCL = 75.95

Mean = 32.99

UCL = 114.20

Mean = 68.85

LCL = 23.50Vaccine standing orders implemented

Per

cent

National Hospital Quality MeasuresPneumonia Vaccine for Pneumonia Patients

* Preliminary data for quality improvement purposes onlyMonth

p chart

Jan-

04 (n

=26)

Feb-0

4 (n

=7)

Mar

-04

(n=8

)

Apr-0

4 (n

=6)

May

-04

(n=1

3)

Jun-

04 (n

=9)

Jul-0

4 (n

=10)

Aug-0

4 (n

=4)

Sep-0

4 (n

=14)

Oct-0

4 (n

=10)

Nov-0

4 (n

=12)

Dec-0

4 (n

=6)

Jan-

05 (n

=25)

Feb-0

5 (n

=13)

Mar

-05

(n=6

)

Apr-0

5 (n

=8)

May

-05

(n=1

1)

Jun-

05 (n

=7)

Sep-0

5 (n

=5)

*Oct

-05

(n=7

)

*Nov

-05

(n=7

)

*Dec

-05

(n=1

0)

*Jan

-06

(n=9

)

20

40

60

80

100

120

UCL = 75.95

Mean = 32.99

UCL = 114.20

Mean = 68.85

LCL = 23.50

Vaccine standing orders implemented

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 is at 61%. National shortages of 2004/05 and local vaccine supply delay in October 2005 should be considered during analysis.

Vaccine standing orders implemented

Per

cent

National Hospital Quality MeasuresInfluenza Vaccine for Pneumonia Patients

* Preliminary data for quality improvement purposes onlyMonth

p chart

Oct-0

4 (n

=16)

Nov-0

4 (n

=17)

Dec-0

4 (n

=11)

Jan-

05 (n

=27)

Feb-0

5 (n

=20)

*Oct

-05

(n=1

3)

*Nov

-05

(n=9

)

*Dec

-05

(n=1

6)

*Jan

-06

(n=1

6)

20

40

60

80

100UCL = 97.20

Mean = 60.69

LCL = 24.18

Vaccine standing orders implemented

Per

cent

National Hospital Quality MeasuresInfluenza Vaccine for Pneumonia Patients

* Preliminary data for quality improvement purposes onlyMonth

p chart

Oct-0

4 (n

=16)

Nov-0

4 (n

=17)

Dec-0

4 (n

=11)

Jan-

05 (n

=27)

Feb-0

5 (n

=20)

*Oct

-05

(n=1

3)

*Nov

-05

(n=9

)

*Dec

-05

(n=1

6)

*Jan

-06

(n=1

6)

20

40

60

80

100UCL = 97.20

Mean = 60.69

LCL = 24.18

Vaccine standing orders implemented

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: Performance is unstable; on average 50% of eligible patients are receiving counseling. Interventions were enacted in February 2006 for all LUMC patients who smoke to receive smoking cessation information.

Per

cent

National Hospital Quality MeasuresSmoking Cessation Advice for Pneumonia Patients

* Preliminary data for quality improvement purposes onlyMonth

p chart

Jan-

04 (n

=8)

Feb-0

4 (n

=5)

Mar

-04

(n=2

)

Apr-0

4 (n

=7)

May

-04

(n=5

)

Jun-

04 (n

=3)

Jul-0

4 (n

=3)

Aug-0

4 (n

=2)

Sep-0

4 (n

=1)

Oct-0

4 (n

=8)

Nov-0

4 (n

=4)

Jan-

05 (n

=3)

Feb-0

5 (n

=4)

Mar

-05

(n=4

)

Apr-0

5 (n

=3)

May

-05

(n=2

)

Jun-

05 (n

=4)

Jul-0

5 (n

=5)

Aug-0

5 (n

=2)

Sep-0

5 (n

=2)

*Oct

-05

(n=2

)

*Nov

-05

(n=3

)

*Dec

-05

(n=2

)

*Jan

-06

(n=8

)

0

50

100

150

200

UCL = 126.61

Mean = 50.00