PURPOSE: Mortality due to severe pneumonia remains high and has shown little improvement in the last three decades. We attempt to determine whether the application of a group of care quality markers in a bundle will improve outcomes of patients with severe community-acquired and health-care associated pneumonia (CAP and HCAP). We will call this the “early bundle”. It consists of 5 evidence-based or expert consensus process markers of quality: 1. Early oxygenation assessment: < 3 hours; 2. Timely initiation of antibiotic therapy; 3. Guideline-concordant antibiotic therapy; 4. Blood cultures before the first antibiotic dose; 5. Intensive Care Unit (ICU) / Intermediate care unit (SCU) admission in the first 24 hours.
METHODS: Retrospective analysis of patients with severe pneumonia, as defined by IDSA/ATS guidelines, requiring admission to the ICU/SCUs at Geisinger Medical Center in Danville, PA, between January and December 2008. We compared clinically relevant outcomes in patients treated according to usual practice (control group) vs. patients in whom all the five elements of the bundle were implemented (early bundle group).
RESULTS: We identified 179 cases of severe pneumonia, 105 (59%) were CAP, 108 (60%) male, 149 (83%) had sepsis/septic shock at onset, etiology was more frequently defined in the control group: 57 (49.6%) vs. 18 (28.1%); p=0.005, and 64 (35.7%) were treated with the “early bundle”. The 2 groups were similar in age, co-morbidities, and severity of illness given by sepsis/septic shock, mechanical ventilation, need of vasopressors and CURB 65 score. In-hospital mortality was lower in the bundle group (25.2% vs. 3.1%; p < 0.001). In the control group cases, 60 (52%) had the first antibiotic dose timely; 57 (50%) were treated with guideline-concordant antibiotic therapy; and 69 (60%) had blood cultures before the first antibiotic dose.
CONCLUSIONS: In this study, patients with severe non-nosocomial pneumonia who were treated with the complete “early bundle” had lower in-hospital mortality.
CLINICAL IMPLICATIONS: The implementation and effective delivery of existing evidence-based therapies in a bundle can decrease mortality in patients with severe pneumonia.
DISCLOSURE: The following authors have nothing to disclose: Luis Diaz, Paula Montana de la Cadena, Rosita Baua, Kevin Maguire, Benny Johnson, Juan Mejia, Jennifer Sartorius, Paul Simonelli
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