PURPOSE: Timing of antibiotics in pneumonia has been shown to reduce 30-day mortality (Meehan) and in-hospital mortality and utilization (Houck). After the inclusion of antibiotic timing as a pay for performance measure, questions about the accuracy of diagnoses have been raised (Kanwar). To address accuracy and performance, we implemented a standardized protocol for triage, treatment and evaluation of pneumonia patients and studied the impact on timing of antibiotics.
METHODS: From January of 2004 to December of 2006, 1307 cases of community acquired pneumonia inpatients admitted through the emergency department were reviewed and confirmed by two physicians. Timing was defined as the interval from triage to administration (minutes). Compliance was the percent of eligible cases per month falling within 4 hours timing. The results of the “collaborative review” process were shared with both emergency and internal medicine departments. In the third quarter of 2004, a “shared accountability” process was implemented: emergency physicians initiated radiographs and laboratories immediately following triage; internists endorsed standardized antibiotic regimens; clinicians and radiology received feedback on performance.
RESULTS: At baseline, from January through March, 2004, 45% of eligible patients (74/163), received antibiotics within 4 hours, averaging 227 minutes. With implementation of “collaborative review,” second quarter compliance rose to 79% (26/33) averaging 180 minutes. After implementation of “shared accountability”, compliance rose to 86% (91/106) averaging 168 minutes. The final quarter of 2004 yielded 94% compliance (125/133) and 143 minutes. From 2005-2006, rates of 90-97% were achieved for all quarters (averaging 124-145 minutes). 2005 statewide 4-hour compliance rates averaged 69% and increased to 74% in 2006 (JCAHO).
CONCLUSION: We demonstrated that a collaborative process involving the Emergency and Medicine departments can achieve antibiotic timing within 4 hours at rates in excess of 90% consistently. A protocol initiated during triage and a robust review process appear to be essential.
CLINICAL IMPLICATIONS: This study shares a clinical improvement process that addresses both accuracy of diagnosis and timing of treatment to achieve process goals associated with improved mortality and morbidity in pneumonia.
DISCLOSURE: Dani Hackner, No Financial Disclosure Information; No Product/Research Disclosure Information