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Low-cost and high quality pneumonia care| HMC client LDS Hospital in Salt Lake City maintains one of the lowest costs of care while providing excellent quality of care in pneumonia, one of the JCAHO core measures, for over a decade. In a HMC iConference call lead by one of the country’s premiere physicians in pneumonia care, LDS discusses how to successfully implement and maintain CAP guidelines. | | Interview with LDS Hospital’s Dr. Nathan C. Dean
How did you decide to start initiating changes in the hospital?
We recognized a need for change when revising policies for administering and screening for the influenza vaccine and Pneumovax. Some significant changes included developing a pre-printed order form that allowed nurses and pharmacists to independently assess and administer the vaccine to people who qualify. This order form did not require any physician’s signature. The policy was created and reviewed by the Intermountain Adult Immunization Committee and the Infection Control Practitioners Committee. The order is placed on every chart with some exceptions. The order form is an assessment tool used for data collection.
In addition, an education packet was sent to the chief nursing officer (CNO), who determined how to best administer it to the facilities. We included a log to track education completion. Licensed nurses and pharmacists who complete the education may independently assess and vaccinate. The Intermountain Medical Directors approved the policy and took it to their facilities to educate their medical staff. Reminders are provided regularly in department meetings.
How do you get people to follow your policies?
This is a difficult process, it takes a lot of years and a marathon effort is required utilizing a variety of team members. We found it important to show everyone our past results and display the variances in quality of care among all the hospitals in our system and within departments. Presenting outcome data provided enthusiasm to create a guideline and to follow a few key steps, thus reducing micromanaging.
Who is responsible to making sure that the bedside nurse is giving the vaccine at the right time?
We have consultants that collect and analyze the data and work with the nursing units. When they identify a problem, they take the data to the appropriate unit manager, who in turn takes the data to educate the staff. We don’t have a designated nurse only for pneumonia patients. Every physician and every nurse is expected to assess and treat pneumonia patients. A greater emphasis is placed on the discharge unit or nurse to administer the flu and pneumonia vaccines because they have the last opportunity to make a difference.
How did you educate the staff?
When the policy was in the making, physicians, nursing, and pharmacy were involved and had bought in on it as important to pursue. The policy was reviewed and approved by a variety of physician groups and other groups, and then it was sent to the medical directors and chief nursing officers. The medical directors then relayed it to their medical staff and the CNOs to the facility managers.
Educating staff is an on going, never-ending process and it required multiple strategies: emails, newsletter, committee members have lunches with other physicians, news media, pharmaceutical industry people who are marketing medications listed in the guidelines, department meetings.
Is there any particular triage process or key statement in the protocol on giving antibiotics to patients within 4 hours?
We leave that up to the individual emergency departments to figure it out. They do not want to stop the flow of other patients to the emergency department. They make sure it’s between diagnosis and before the patient leaves the E.D. There needs to be an agreement among all physicians on which antibiotics are going to be used ahead of time. This process saves a large amount of time.
Describe CURB 65.
We use CURB 65 to assess our CAP patients, which is a severity-scoring system for pneumonia. In a European study by the British Thoracic Society, four variables reflecting acute pneumonia-associated morbidity were shown to be predictive of death from pneumonia: the presence of confusion (C) and blood urea nitrogen (U), respiratory rate (R), and blood pressure (B) at defined thresholds.
This scale helps drive whether the patient goes to the ward, hospital, is discharged out of the ER or to the ICU. The patients for the floor, the recommendation are doxycyclin and ceftriaxone (Rocephin) as the default, with levofloxacin as an alternative in case of allergies. In the ICU, patients get intravenous azithromycin and intravenous ceftriaxone. The medication is given by where they are driven to the hospital, which is determined, by the physician and the CURB 65 score.
How does Smoking Cessation Counseling fit into the pneumonia guidelines?
This was not implemented through the guideline, but via another team. The informatics team has integrated it as part of the electronic charting system. It prompts nurses and respiratory therapists to provide smoking cessation to facilities where we have electronic charting.
Is there anything specific in the patient history form that allows it to act as the first screening tool?
There is one line that asks specifically “Have you had the influenza or pneumonia vaccine in the past 12 months?” The old patient forms did not have this question 10-15 years ago. This is a pretty important change.
How is it possible to maintain continuous medical education? How do you sustain it?
Every year, we look at the policy, process and outcome data. Then we revise our policy based on feedback and outcome data. The education depends on the season and how a particular service area is performing. When influenza season comes up, we do much more education for the flu vaccine and that also ties to pneumonia care education. If you look at the data, you’ll see that the more education given, the better the outcome data look. It’s all about staying aware of the issue.
How did you get pharmaceutical firms to help with educating the medical teams?
Hospitals and outpatient health plan sites both have contracts with particular vendors. Now hospitals get more generic drugs to treat pneumonia, so pharmaceutical contracting is happening less, but in the past, LDS would get companies whose drugs were written in the protocol to educate the medical teams. Contract leverage and some salesmanship help to get the education on pneumonia rolling.
What are the next steps at LDS? Where are you pointing your future initiatives for improvement in pneumonia?
We cannot be complacent. We’ll continue to monitor outcome data, educate, and report internally and externally. We hope to develop a computerized documentation system to screen for vaccines history and for ordering care for patients who are known to have pneumonia. The informatics team will do the same thing that was done for smoking cessation counseling (see question above). They are going to have to work on figuring out processes that can be standardized in order to put into the electronic system. Mostly, we want to be better at exchanging information and learn what others are doing.
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