PNEUMONIA

Team Membership:

Susan A . Tuzik, MS, RNRose Lach, Administrative Director

Clinical Departments: Emergency Medical Services, General Medicine, Cardiac Services

Hospital Departments: 6 Northeast, 3NESW, 2 NE, Emergency Department, Medical Records, Quality & Resource Management, Center for Clinical Effectiveness

Confidential: For Quality Improvement Purposes Only

Forces of Magnetism

• Force 6: Quality of Care• Force 7: Quality Improvement• Force 9: Autonomy• Force 13: Interdisciplinary Relationships

Confidential: For Quality Improvement Purposes Only

Room for Improvement

To increase the rates for those quality measures specific to the Pneumonia Core measure:

• Antibiotic timing• Appropriate Antibiotic Administered• Adult Smoking Cessation Counseling• Blood Culture Collection• Pneumococcal Vaccination: > 65 years of age• Influenza Vaccination: > 50 years of age

Confidential: For Quality Improvement Purposes Only

Goals

• Initial antibiotics administered within 6 hours of arrival at hospital

• Appropriate antibiotic administered

• Blood cultures collected prior to initial antibiotic dose

• 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

Confidential: For Quality Improvement Purposes Only

Plan

• Appropriate antibiotics in ED Omnicell and as floor stock

• Daily monitoring of all inpatient pneumonia patients

• “No Flu” posters to be placed in patient rooms (October-December)

• Pneumovax/ Influenza in-services to inpatient units

• Pneumovax/ Influenza screening orders added to Epic discharge instructions

• Participation in Patient Safety Fair

Confidential: For Quality Improvement Purposes Only

Next Steps

• Continue to provide in-services for inpatient units to increase compliance of Pneumococcal and Influenza vaccination screening and administration

• Continue to monitor effectiveness of vaccination orders as part of the discharge summary instructions in Epic

• Create individual nurse specific reports for vaccine screening and administration on a quarterly basis

Confidential: For Quality Improvement Purposes Only

Accomplishments

• Pneumonia Core Measure presentations provided to various nursing units as needed or requested

• Presentations at the nurse manager’s meetings

• Ongoing communication with nurse managers and nurses regarding outliers

• Developing nurse specific outlier reports for ongoing education and awareness

Confidential: For Quality Improvement Purposes Only

Definition: Collection of blood cultures in the emergency department prior to first dose of antibiotic / pneumonia patients who received blood cultures and antibiotics after arrival.

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

Analysis: LUMC performance is consistent at 93%.

ED Standing Orders based on symptoms and age to

allow RN to deliver specific antibiotics, draw blood

culture, and order chest x-ray

Pe

rce

nt

Pneumonia Patients Receiving Blood Cultures in the Emergency Dept Before First Antibiotic

Month

UCL = 111.0

Mean = 93%

LCL = 75.1

Jan 2

006

(n=2

0)

Feb 2

006

(n=2

2)

Mar

200

6 (n

=16)

Apr 200

6 (n

=20)

May

200

6 (n

=12)

Jun 2

006

(n=1

2)

Jul 2

006

(n=1

1)

Aug 200

6 (n

=16)

Sep 2

006

(n=1

6)

Oct 2

006

(n=1

5)

Nov 20

06 (n

=14)

Dec 2

006

(n=2

0)

Jan 2

007

(n=2

6)

Feb 2

007

(n=1

5)

Mar

200

7 (n

=34)

Apr 200

7 (n

=19)

May

200

7 (n

=17)

Jun 2

007

(n=1

1)

Jul 2

007

(n=1

9)

Aug 200

7 (n

=7)

Sep 2

007

(n=3

0)

Oct 2

007

(n=1

3)

Nov 20

07 (n

=18)

Dec 2

007

(n=1

6)

Jan 2

008

(n=2

3)

Feb 2

008

(n=1

8)

Mar

200

8 (n

=28)

0

20

40

60

80

100

120

ED Standing Orders based on guidelines that allow RN to order chest x-ray, blood culture & deliver first dose antibiotic

Confidential: For Quality Improvement Purposes Only

Definition: Pneumonia patients who receive initial antibiotic within 6 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 now consistent at 89%. A team of physicians and nurses are actively working to ensure that all patients with pneumonia receive initial antibiotics within 6 hours of arrival. August 2007 represents 4 patients, and no significant change in performance.

Pe

rce

nt

Pneumonia Patients Receiving Initial Antibioticwithin 6 Hours of Hospital Arrival

Month

UCL = 111.2

Mean = 79%

LCL = 47.7

UCL = 111.8

Mean = 89%

LCL = 66.1

Jan 2

006

(n=1

7)

Feb 2

006

(n=1

5)

Mar

200

6 (n

=16)

Apr 200

6 (n

=19)

May

200

6 (n

=9)

Jun 2

006

(n=1

3)

Jul 2

006

(n=1

0)

Aug 200

6 (n

=14)

Sep 2

006

(n=1

9)

Oct 2

006

(n=1

7)

Nov 20

06 (n

=13)

Dec 2

006

(n=1

3)

Jan 2

007

(n=2

4)

Feb 2

007

(n=1

4)

Mar

200

7 (n

=25)

Apr 200

7 (n

=16)

May

200

7 (n

=12)

Jun 2

007

(n=9

)

Jul 2

007

(n=1

8)

Aug 200

7 (n

=4)

Sep 2

007

(n=2

2)

Oct 2

007

(n=1

5)

Nov 20

07 (n

=14)

Dec 2

007

(n=1

9)

Jan 2

008

(n=1

8)

Feb 2

008

(n=1

7)

Mar

200

8 (n

=27)

0

20

40

60

80

100

120

140

ED Standing Orders based on guidelines that allow RN to order chest x-ray, blood culture & deliver first dose antibiotic

Confidential: For Quality Improvement Purposes Only

Definition: Immunocompetent non-intensive care unit 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 improved significantly, following process changes in the emergency department in January 2007, but has fallen in recent months.

Pe

rce

nt

Pneumonia non-ICU Patients Receiving Initial Antibiotic SelectionConsistent with Current Guidelines

Month

UCL = 118.5

Mean = 92%

LCL = 65.2

UCL = 115.8

Mean = 97%

LCL = 78.3

Jan 2

006

(n=1

1)

Feb 2

006

(n=1

2)

Mar

200

6 (n

=14)

Apr 200

6 (n

=10)

May

200

6 (n

=6)

Jun 2

006

(n=9

)

Jul 2

006

(n=3

)

Aug 200

6 (n

=6)

Sep 2

006

(n=1

1)

Oct 2

006

(n=1

0)

Nov 20

06 (n

=5)

Dec 2

006

(n=8

)

Jan 2

007

(n=1

8)

Feb 2

007

(n=1

0)

Mar

200

7 (n

=17)

Apr 200

7 (n

=7)

May

200

7 (n

=6)

Jun 2

007

(n=5

)

Jul 2

007

(n=5

)

Aug 200

7 (n

=1)

Sep 2

007

(n=9

)

Oct 2

007

(n=6

)

Nov 20

07 (n

=6)

Dec 2

007

(n=9

)

Jan 2

008

(n=4

)

Feb 2

008

(n=5

)

Mar

200

8 (n

=12)

0

20

40

60

80

100

120

140

ED Standing Orders based on guidelines that allow RN to order chest x-ray, blood culture & deliver first dose antibiotic

Confidential: For Quality Improvement Purposes Only

Definition: Collection of blood culture within the first 24 hours after arrival / pneumonia patients who were transferred to an intensive care unit within 24 hours of hospital arrival.

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

Analysis: LUMC performance has been 89% for this measure since July 2007.

Pe

rce

nt

Pneumonia Patients Receiving Blood Cultures Within 24 Hours for those Admitted to the ICU Within 24 Hours of Hospital Arrival

Month

UCL = 124.7

Mean = 94%

LCL = 64.0

Jan 2

006

(n=8

)

Feb 2

006

(n=3

)

Mar

200

6 (n

=1)

Apr 200

6 (n

=7)

May

200

6 (n

=5)

Jun 2

006

(n=4

)

Jul 2

006

(n=3

)

Aug 200

6 (n

=4)

Sep 2

006

(n=6

)

Oct 2

006

(n=3

)

Nov 20

06 (n

=5)

Dec 2

006

(n=7

)

Jan 2

007

(n=5

)

Feb 2

007

(n=5

)

Mar

200

7 (n

=8)

Apr 200

7 (n

=7)

May

200

7 (n

=2)

Jun 2

007

(n=5

)

Jul 2

007

(n=8

)

Aug 200

7 (n

=5)

Sep 2

007

(n=7

)

Oct 2

007

(n=6

)

Nov 20

07 (n

=4)

Dec 2

007

(n=5

)

Jan 2

008

(n=8

)

Feb 2

008

(n=5

)

Mar

200

8 (n

=5)

0

20

40

60

80

100

120

140

160

Confidential: For Quality Improvement Purposes Only

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: LUMC performance dropped significantly in November 2007, but recovered in 2008. This timing correlates with nursing documentation go-live and transition in project related quality coaching.

Pe

rce

nt

Pneumonia Patients Receiving Pneumococcal Vaccination

Month

UCL = 112.9

Mean = 82%

LCL = 51.8

Jan 2

006

(n=1

1)

Feb 2

006

(n=1

6)

Mar

200

6 (n

=13)

Apr 200

6 (n

=15)

May

200

6 (n

=11)

Jun 2

006

(n=8

)

Jul 2

006

(n=7

)

Aug 200

6 (n

=9)

Sep 2

006

(n=1

1)

Oct 2

006

(n=1

7)

Nov 20

06 (n

=10)

Dec 2

006

(n=1

6)

Jan 2

007

(n=2

4)

Feb 2

007

(n=1

6)

Mar

200

7 (n

=24)

Apr 200

7 (n

=16)

May

200

7 (n

=12)

Jun 2

007

(n=8

)

Jul 2

007

(n=1

6)

Aug 200

7 (n

=6)

Sep 2

007

(n=2

0)

Oct 2

007

(n=1

1)

Nov 20

07 (n

=15)

Dec 2

007

(n=1

7)

Jan 2

008

(n=1

3)

Feb 2

008

(n=9

)

Mar

200

8 (n

=28)

0

20

40

60

80

100

120

Nursing Go-Live

Pneumonia team transition

Confidential: For Quality Improvement Purposes Only

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 was at 76% for the 2006 and 2007 flu seasons, but dropped to 58% for the 2008 flu season. Nursing leaders are actively working on strategies to ensure the provision of influenza vaccination to all appropriate patients.

Pe

rce

nt

Pneumonia Patients Receiving Influenza Vaccination

Month

UCL = 97.1

Mean = 67%

LCL = 36.8

Jan 2

006

(n=1

6)

Feb 2

006

(n=1

9)

Nov 20

06 (n

=19)

Dec 2

006

(n=1

9)

Jan 2

007

(n=3

6)

Feb 2

007

(n=1

7)

Oct 2

007

(n=1

6)

Nov 20

07 (n

=22)

Dec 2

007

(n=2

3)

Jan 2

008

(n=2

2)

Feb 2

008

(n=1

6)

Mar

200

8 (n

=38)

0

20

40

60

80

100

Nursing Go-Live

Pneumonia team transition

Confidential: For Quality Improvement Purposes Only

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 at 93% with only 2 patients missed in the past 18 months.

Pe

rce

nt

Smokers Receiving Smoking Cessation Advice for Pneumonia Patients

Month

UCL = 126.1

Mean = 93%

LCL = 60.0

Jan 2

006

(n=9

)

Feb 2

006

(n=5

)

Mar

200

6 (n

=3)

Apr 200

6 (n

=2)

May

200

6 (n

=5)

Jun 2

006

(n=4

)

Jul 2

006

(n=2

)

Aug 200

6 (n

=6)

Sep 2

006

(n=5

)

Oct 2

006

(n=8

)

Nov 20

06 (n

=4)

Dec 2

006

(n=3

)

Jan 2

007

(n=8

)

Feb 2

007

(n=5

)

Mar

200

7 (n

=9)

Apr 200

7 (n

=6)

May

200

7 (n

=4)

Jun 2

007

(n=1

)

Jul 2

007

(n=9

)

Aug 200

7 (n

=7)

Sep 2

007

(n=7

)

Oct 2

007

(n=4

)

Nov 20

07 (n

=4)

Dec 2

007

(n=7

)

Jan 2

008

(n=5

)

Feb 2

008

(n=7

)

Mar

200

8 (n

=5)

0

20

40

60

80

100

120

140

160

Confidential: For Quality Improvement Purposes Only