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Two years ago, Pomona Valley Hospital Medical Center’s case management team, along with the decision support department and the administrators, realized that community-acquired pneumonia (CAP) was a diagnosis-related group that needed to be revisited in their organization. "We weren’t competitive with any of our local facilities," says Maria Robles, RN, respiratory case manager for the Claremont, CA, hospital. "We also knew from our experience that there was so much variation in practice that the patients weren’t getting any standard of care." Physicians and nurses were treating patients with different antibiotics, with and without preventive care, and so forth.
After a chart review of 1999’s January to December patients, a new pathway for CAP was developed, which reduced length of stay (LOS) by an overall 1.1 days, saving somewhere around $1,000 per case. (To see the pathway, click here.) "We implemented the risk-class system that was designed by the Infectious Society of America and the American Thoracic Society (ATS). It’s a scoring system based on severity of illness for CAP," Robles says.
Their guidelines categorize risk Class 5 patients as those with the highest mortality rate, and Class 1 or Class 2 as patients not necessarily needing hospitalization. The bulk of cases studied fell in the Class 3 and Class 4 range, and average LOS for those patients improved even more: seven days for nonpathway Class 4 patients, vs. 4.6 days for pathway Class 4 patients. "One of the interventions [of the pathway] was that patients get out of bed within 48 hours," Robles notes. Comparatively, patients on the pathway achieved that goal 91% of the time, while nonpathway patients only achieved 77%. "Getting out of bed prevents embolisms, which can go to the head and produce a stroke, as well as preventing other complications including bedsores," she says.
Additionally, the pathway team knew that addressing patients’ conversion from intravenous (IV) antibiotics to oral antibiotics was important in reducing overall LOS. Conversion can reduce the risk of the complications from invasive IV medication — phlebitis, systemic infection, and other problems, Robles adds. Pathway patients converted on day three twice as much as nonpathway patients (18% vs. 9%).
"One thing we did really badly on was collecting sputum before the antibiotic is administered," Robles says. (On the pathway, 27% of CAP patients had sputum tests done before antibiotic administration.) Testing sputum is necessary to identify the organisms causing the illness. However, there’s some controversy between the Infectious Society of America and the ATS about how mandatory this action should be.
"It’s very hard to get a good sample. You need phlegm from deep in the lungs, and it’s just hard to get. Some people are too weak to cough that deeply; sometimes it’s just too deep in the lower lobes. The pathway didn’t produce any better results in getting those sputums out, and we had some fighting among our physicians about whether or not we needed to get it," Robles says. "In the ideal world," she points out, "we need to absolutely know [the organism], but the other important goal is to give the antibiotics within two hours of presentation, because that decreases mortality very significantly."
Pomona did very well improving its antibiotic administration. On the pathway, the benchmark was two hours, and in 2000, the pathway patients received it, on average, within 2.59 hours. Non-pathway patients in 1999 had an average of 6.1 hours delivery time. One final improvement was in preventive treatment for CAP patients. The pathway research included a significant change: In 2000, 100% of pathway patients who needed flu and pneumococcal vaccinations were given them upon discharge, whereas in 1999, that percentage had been only 4.5%.
Since Pomona developed its CAP pathway in 1999, revised guidelines about new antibiotic treatment have been released by the Infectious Society and ATS. Robles says the department plans to revise its pathway in accordance with the new data. "These data are from recommendations for 1998, and there have been new ones now. We need to revise all the orders for what antibiotics come next, according to the new guidelines from the two groups." But revision has been part of the plan since its inception. We worked very hard on a system that would function effortlessly; the pathway wouldn’t require someone to constantly follow it, so that any nurse or physician from any specialty could use it. If we continue to pursue it this year, and we will, we could probably cut another day," Robles says.
In addition, Pomona didn’t want to make the initial pathway a sudden, 180-degree change. "We felt that in order to change the culture of our facility, we needed to do it in steps. It’s a best practice, but it’s not yet the ideal practice. So, with revision, it will get even closer to the ideal," she explains.
Several specialties were involved with the development of the pathway — pulmonologists, infectious disease specialists, family practitioners, rehab specialists, administration, nursing, physical therapy, and the dietician — so we have a lot of buy-in, and that empowers the staff, she adds. "It’s important to work as a team and have a lot of physician involvement, because they are the ones who have to feel that the data are worth it. We had some very reputable pulmonologists and infection doctors who were the lead physicians on the project," says Robles.
[For more information, contact: Maria Robles, RN, Respiratory Case Manager, Pomona Valley Hospital Medical Center, 1569 Mural Drive, Claremont, CA 91711. Telephone (909) 469-9464.]
Hospital Case Management welcomes guest columns about clinical path development and use. Articles should include any results (length of stay, cost, or process improvements) that use of your pathway has helped achieve and should be from 800 to 1,200 words long. Send article submissions to: Lee Reinauer, editor, Hospital Case Management, P.O. Box 740056, Atlanta, GA 30374. Telephone: (404) 262-5460. Fax: (404) 262-5447.