Improving Management of Community Acquired Pneumonia through Collaborative Integrated Care in an Antimicrobial Stewardship initiativeM. Sehu1, T. Patterson2,3, K. Houghton3, P. Firman3, Z. Klyza2,3, D. McDougall1

1Infection Management Services, Princess Alexandra Hospital , 2Infection Management Services, Logan Hospital, 3Pharmacy Department, Logan Hospital

BackgroundLogan Hospital is a 440 bed hospital for one of the fastest growing regions in Queensland. It is one of five hospitals in the Metro South Hospital and Health Service, the largest Hospital and Health Service in South East Queensland that provides healthcare to a population of more than 1 million people, 23% of Queensland’s population.

InterventionStriving to achieve best practice is implicit in the definition of a multidisciplinary evidence based clinical pathway in which the different tasks of professionals involved in patient care are defined, optimized and sequenced. Clinical pathways have been shown to effectively manage and improve quality in healthcare.6

A fully integrated clinical pathway for the management of CAP in immuno-competent adult patients was developed under the leadership of an Infectious Diseases physician in collaboration with clinicians from Respiratory, General Medicine, Emergency Department (ED) and Intensive Care; as well as input from Nursing, Pharmacy and Allied Health. The pathway is designed to replace the inpatient progress notes and follows the patient journey from presentation and initial assessment in ED to day four of their admission. The tasks of each health professional are defined, optimised and sequenced. Also included is a guide to clinical assessment, a severity assessment tool and a treatment algorithm for empirical antibiotic management.

In addition to the pathway itself, patient information leaflets were developed to assist with patient education and support the early discharge of patients directly from ED where appropriate. To facilitate appropriate antibiotic prescribing at discharge, CAP “pre-packs” were introduced into the ED imprest.

ResultsThe Baseline demographics of our patient group did not differ significantly between the years audited.

References1. Bosso JA and Drew RH Application of antimicrobial stewardship to optimise management of community acquired pneumonia Int J Clin Pract July 2011, 65(7): p 775-7832. Adler NR et al Adherence to Therapeutic Guidelines for Patients with Community-Acquired Pneumonia in Australian Hospitals Clinical Medicine Insights: Circulatory, Respiratory and Pulmonary Medicine 2014:8 17-20 3. Trad, M-A and A. Baisch, Management of community-acquired pneumonia in an Australian regional hospital. The Australian Journal Of Rural Health, 2017. 25(2): p. 120-124. 4. Sakamoto, Y., et al., Guidelines-concordant empiric antimicrobial therapy and mortality in patients with severe community-acquired pneumonia requiring mechanical ventilation. Respiratory Investigation, 2017. 55(1): p. 39-44.5. Lee, J.S., et al., Antibiotic Therapy for Adults Hospitalized With Community-Acquired Pneumonia: A Systematic Review. JAMA, 2016. 315(6): p. 593-602. 6. Rotter T, Kinsman L, James E, et al. Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs. Cochrane Database Syst Rev. 2010;3:CD006632.7. Charles PG et al SMART_COP: a tool for predicting the need for intensive respiratory or vasopressor support in community0acquired pneumonia Clin Infect Dis 2008 Aug 1; 47(3) 375-848. Robins-Browne KL et al, The SMART-COP score performs well for pneumonia risk stratification in Australia’s Tropical Northern Territory: A prospective cohort study Trop Med Int Health July 2012 (17)7: 914-9199. Charles PG et al The etiology of community-acquired pneumonia in Australia: why penicillin plus doxycycline or a macrolide is the most appropriate therapy Clin Infect Dis 2008 May 15; 46(10)13-2110. Community acquired pneumonia in adults [revised 2014 Oct]. In: eTG complete [internet]. Melbourne: Therapeutic Guidelines Limited; 2017 Jun.

The drive for this program came from the prescribing of antibiotics outside recommended guidelines for the treatment of Community Acquired Pneumonia (CAP) that was noted as a result of Antimicrobial Stewardship (AMS) activities at Logan Hospital.

Community acquired pneumonia is a common condition with significant morbidity and mortality especially in the elderly. Studies in the United States report a 12% death rate associated with patients admitted to hospital with CAP. Patients who survive hospitalisation are vulnerable to readmission with a resulting economic impact of CAP estimated to be $12.2 billion dollars in 1996-98, 90% of which is attributed to hospital care1.

Inappropriate selection of antibiotics in the management of CAP has frequently been reported in the literature, including within the Australian setting2,3. Adherence to evidence-based guidelines can have a profound impact on patient outcomes and healthcare costs4. Guidelines have been shown to improve short-term prognosis in patients with severe CAP who require ventilation in hospital. AMS efforts have demonstrated decreased use of broad spectrum antibiotics, earlier switch from intravenous to oral therapy, with overall shorter duration of therapy and decreased length of stay in hospital5.

Clinical pathways have been shown to improve quality in healthcare.6 Clinical pathways have been shown to be effective tools in the management of CAP, encouraging greater adherence to recommended treatment guidelines and the use of severity assessment tools in the decision making process. We have chosen to use the SMART-COP tool as it was well validated in the Australian Community Acquired Pneumonia Study (ACAPS)7 and more recently noted to have worked well for patients in the Northern Territory8. Antimicrobial recommendations have been formulated based on the findings from ACAPS9, the Therapeutic Guidelines10 and consideration of the local antibiogram of common CAP pathogens.

A baseline retrospective audit of antimicrobial use in Community Acquired Pneumonia (CAP) conducted in the winter of 2011 revealed high rates of inappropriate prescribing that was not concordant with established guidelines. It was proposed to improve the management of CAP with the implementation of a clinical pathway, designed to pull together best practice guidelines for the management of pneumonia across all disciplines involved in the care of these patients.

Susceptibility of Streptococcus pneumonia

Year 2013 2014 2015 2016 2017Non blood / urine isolate 80% 87% 84% 83% 89%No Pen I / Pen R 15%, 8% 10%, 3% 15%, 3% 14%, 3% 1%, <1%

Year 2013 2014 2015 2016 2017Blood isolates (number) 19 19 12 19 22No Pen I / Pen R 0%, 0% 0%, 0% 17%, 0% 5%, 0% 9%, 5%

Data: Pathology Queensland Antibiograms (2010-2016) on https://qheps.health.qld.gov.au/hsq/pathology/antibiograms Accessed 13/2/18 2017 Data Courtesy of Dr Claire Heney

Baseline Data

Issue Identified CAP 2012(n=80)

Use of a Severity Assessment Tool by a Medical Officer 9%

ED % of azithromycin prescriptions for < severe CAP 79% (n=40)

% ceftriaxone prescriptions no penicillin allergy 67% (n=33)

Inpatient % of azithromycin prescriptions for < severe CAP 63% (n=38)

% ceftriaxone prescriptions no penicillin allergy 63% (n=32)

Within the CAP Pathway, there are promptings for best practices when it comes to VTE prophylaxis, intravenous cannula management and care, pressure area care and infection control prompts regarding hand hygiene and cough etiquette. The focus of the pathway did not just end with the patient journey in hospital. It included ongoing follow up with the general practitioner through a prompt to complete a discharge summary, pharmacy input to ensure any changes to medication is well documented in a Discharge Medication Record and ongoing follow up tests and appointments are arranged.

In striving to provide patient centred, holistic multi-disciplinary care, the CAP Pathway has incorporated elements of preventative care that can affect outcome in patients who are admitted with pneumonia, namely smoking cessation and vaccination. As CAP mainly affects the elderly, the need for a nutritional assessment and physiotherapy referral guidelines are contained within the Pathway to assist clinicians in initiating the appropriate referral when required.

The CAP pathway was implemented in June 2013 with the strong support of hospital administration and an extensive marketing and education campaign, commencing four weeks prior to the start date. Awareness was raised using memes as screen savers on the hospital computers in addition to the face to face education session.

Utilisation of a severity assessment tool improved with the implementation of the CAP Pathway.

There was improved compliance with Prescribing Guildelines in all areas audited – Emergency Department, in-hospital prescribing and on discharge from hospital. The decrease in the prescribing of restricted antibiotics was seen both in ED as well as in-hospital.

ConclusionOur success stems from having: • Clearvisionandagenda • Consistencyofapproach • Multi-disciplinaryinputandownership(Respiratory,Emergency,Generalphysiciansand Intensivists) • Accountabilitythroughfeedbackofdatacollected • SeniorExecutiveandDirectorsupport • Adequateresourcing • EmpoweringthroughtrainingThe optimisation of care of patients with Comminuty Acquired Pneumonia has been a worthwhile Antimicrobial Stewardship intervention for our hospital.

2012 2013 2014 2015 2016Gender% Female 55% (44) 48% (38) 54% (43) 51% (41) 54% (43)AgeMedian 60.5 62.5 56 47.5 52Range 19-101 18-94 20-91 18-91 21-102SMARTCOPMild 64% (51) 67% (54) 59% (47) 69% (55) 65% (51)Moderate 26% (21) 25% (20) 24% (9) 17% (14) 29% (23)Severe 10% (8) 8% (6) 17% (14) 14% (11) 6% (5)ALOS J18.0, J18.8, J18.9 (all patients Jun - Aug)Days 7.14 5.51 5.42 4.31 5.18

Demographics

Annual use of severity assessment tool (SAT)

Compliance with prescibing guidelines

Prescibing of target antimicrobials - ceftriaxone (CRO), azithromycin (AZT) & amoxicillin-clavulanate (ADF)

Poster produced by Patient Safety & Quality Unit, Princess Alexandra Hospital, 2018

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Definition: Acuteonsetofafebrile illnessaccompaniedbyconsolidation on x-ray or clinical signs of consolidationinindividualswhoarenotinhospital(orinhospitallessthan48hours).ThisdoesnotincludeinfectiveexacerbationofCOPD,bronchiectasisorotherchroniclungdiseases.Ifthepatientisimmuno-compromised,discusstreatmentwithparentunitorInfectiousDiseases.Someoftheinformationonthispathwaymaybeusefulforthesepatients

Medical Officer Name: ........................................................................ Signature: .................................................

Interpretation of SMART-COP score0to2points-lowriskofneedinginvasiverespiratoryorvasopressorsupport(IRVS)

Milddisease-requiresoraltherapyonly.Reviewredflags-mayalsorequireadmission

3to4points-moderaterisk(1in8)ofneedingIRVS Moderatedisease-requiresadmissionfororalandIVtherapy

5to6points-highrisk(1in3)ofneedingIRVS ASMART-COPscoreof5ormorepointsindicatessevereCAPrequiringadmissionunderRespiratoryUnit/HDU/ICU7ormorepoints-veryhighrisk(2in3)ofneedingIRVS

All Staff providing care for the patient please complete the Signature Log belowInitial Printed name Position Initial Printed Name Position

LOGANBAYSIDEHEALTHNETWORK Community Acquired Pneumonia

Clinical Pathway Immuno-competent Adult

Part A: Emergency DepartmentFacility:......................................................

50 years old or less SCORES systolicBP.........If<90mmHg(2pts)

M multi-lobarCXRinvolvement?Y/N.IfY(1pt)

A albumin.........g/L.If<35(1pt)

R resprate.........breaths/min.If>25(1pt)

T tachycardia,pulse..........If>125bpm(1pt)

C confusion,acutelyconfused?Y/N.IfY(1pt)

O oxygenlow(2pts)IfPaO2<70mmHg,onroomair,orIfO2saturation<93%,onroomair,orIfPaO2/FiO2<333

P pH..........If<7.35(2pts)

Total Score (maximum 11)

More than 50 years old SCORES systolicBP.........If<90mmHg(2pts)

M multi-lobarCXRinvolvement?Y/N.IfY(1pt)

A albumin.........g/L.If<35(1pt)

R resprate.........breaths/min.If>30(1pt)

T tachycardia,pulse..........If>125bpm(1pt)

C confusion,acutelyconfused?Y/N.IfY(1pt)

O oxygenlow(2pts)IfPaO2<60mmHg,onroomair,orIfO2saturation<90%,onroomair,orIfPaO2/FiO2<250

P pH..........If<7.35(2pts)

Total Score (maximum 11)

CAP confirmed on chest x-ray

NB: ClinicalPathwaysnever replace clinical judgement.Careoutlinedinthispathwaymustbealteredifitisnotclinicallyappropriatefor theindividualpatient.

Red Flags - Pneumonia Requiring Hospital AdmissionThepresenceofanyoneofthefollowingkeyfeaturesindicatesahighlikelihoodofthepatienthavingseverediseaseandthesepatientsrequireinpatientcare:

Clinical• respiratoryrategreaterthan30breaths/min• systolicbloodpressurelessthan90mmHg• oxygensaturationlessthan92%onroomair• acuteonsetconfusion

Investigations• multi-lobarinvolvementonchestx-ray• acutekidneyinjury• arterialpHlessthan7.35orvenouspHlessthan7.30• partialpressureofoxygen(PaO2)lessthan60mmHg

Medical Officer use SMART-COP to assess disease severity Date: .......... / .......... / ........... Time: ......... : ........ (24hourtime)

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At presentation Date: ..... / ..... / ..... Time ....... : ....... (24hourtime)

Initial/Time Notes (eg.variations)

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TestsAimtodopriortoantibioticadministrationbutdonotdelayantibiotics>4hrfrompresentation

CXRO2sat-ABGifsat<92%onroomairSputumGramstain+culture.SputumAFBifupperlobeorcavitydisease.SeeInfectionControlguidelinesforisolationprocedures.Nasopharyngealswab-RespiratoryvirusPCRUrine-Pneumococcal/LegionellaAG,ifrequiredAtypicalpneumoniaserologyformycoplasmaandlegionellaFBC,U&EBloodculturesx2,iffebrile

MedicationsEmergencyRMOtowriteupantibiotics

Antibioticswithin4hoursofpresentationOxygenwithhumidificationtokeepO2sat>92%(careinCO2retainingpatients,ifknownCOPDpatientorpatientsatriskofhypercapnia)Bronchodilatorsasrequired.IVfluids8hourly(careinpatientswithCCF).Adequateanalgesiaifpleuriticpain.AssessmentforVTEProphylaxis

Consults IFSEVEREonSMART-COPscoring:Respiratoryconsult+/-admittoRespiratoryUnit/HDU/ICUConsiderphysiotherapyconsultifrequiredIfMST(MalnutritionScreeningTool)>2refertodietitian

Expected Outcomes

• IVantibioticsadministeredwithin4hours• Patientcareinitiatedasperclinicalpathway• PatientstatessatisfactionwithcareinEmergencyDepartment

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TreatmentPlanbasedonSMART-COPscorebelow(please tick)

MildCAP:SMART-COPscore0-2 ModerateCAP:SMART-COPscore3-4 SevereCAP:SMART-COPscore5+

Discharge Home

- Ifnilco-morbidities(seeRedFlags)present

- IfGPreviewpossiblewithin24-48hours

- Amoxicillin1gpo8hourlyfor5days

Refer to Acute Care at Home (AC@H)

- Ifco-morbidities(seeRedFlags)present

- IfnilGPreviewwithin24-48hours - Amoxicillin1gpo8hourlyfor5days

NB:Innon-immediatetypepenicillinhypersensitivity,omitamoxicillinandusecefuroxime500mgpo12hourly.NB:Inimmediatepenicillinhypersensitivity,omitamoxicillinandusedoxycycline200mgpostatthen100mg12hourlyORroxithromycin300mgpodaily.

Admit to hospitalRefertomedicalteam

Benzylpenicillin1.2gIV6hourly

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Admit to hospitalUnderRespiratoryUnit/HDU/ICU

Benzylpenicillin 1.2gIV4hourly

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Azithromycin500mgIVdailyfor3days

NB:Innon-immediatetypepenicillinhypersensitivity,useceftriaxone1gIVdailyForpatientswithimmediatepenicillinhypersensitivity:seekInfectious

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LOGANBAYSIDEHEALTHNETWORK Community Acquired Pneumonia

Clinical Pathway Immuno-competent Adult

Part A: Emergency DepartmentFacility:......................................................