A quality improvement initiative to improve adherence to national guidelines for empiric management of community-acquired pneumonia in emergency departments.

OBJECTIVE The objective of this study was to improve the concordance of community-acquired pneumonia management in Australian emergency departments with national guidelines through a quality improvement initiative promoting concordant antibiotic use and use of a pneumonia severity assessment tool, the pneumonia severity index (PSI). DESIGN and INTERVENTIONS Drug use evaluation, a quality improvement methodology involving data collection, evaluation, feedback and education, was undertaken. Educational interventions included academic detailing, group feedback presentations and prescribing prompts. SETTING AND PARTICIPANTS Data were collected on 20 consecutive adult community-acquired pneumonia emergency department presentations by each hospital for each of three audits. MAIN OUTCOME MEASURES Two process indicators measured the impact of the interventions: documented PSI use and concordance of antibiotic prescribing with guidelines. Comparisons were performed using a Chi-squared test. RESULTS Thirty-seven hospitals, including public, private, rural and metropolitan institutions, participated. Twenty-six hospitals completed the full study (range: 462-518 patients), incorporating two intervention phases and subsequent follow-up audits. The baseline audit of community-acquired pneumonia management demonstrated that practice was varied and mostly discordant with guidelines. Documented PSI use subsequently improved from 30/518 (6%, 95% confidence interval [CI] 4-8) at baseline to 125/503 (25%, 95% CI 21-29; P < 0.0001) and 102/462 (22%, 95% CI 18-26; P < 0.0001) in audits two and three, respectively, while concordant antibiotic prescribing improved from 101/518 (20%, 95% CI 16-23) to 132/462 (30%, 95% CI 26-34; P < 0.0001) and 132/462 (29%, 95% CI 24-33; P < 0.001), respectively. CONCLUSIONS Improved uptake of guideline recommendations for community-acquired pneumonia management in emergency departments was documented following a multi-faceted education intervention.

[1]  M. Fine,et al.  Effect of Increasing the Intensity of Implementing Pneumonia Guidelines , 2005, Annals of Internal Medicine.

[2]  Jane M. Young,et al.  Audit and feedback: effects on professional practice and healthcare outcomes. , 2012, The Cochrane database of systematic reviews.

[3]  David N Fisman,et al.  Guideline-concordant therapy and reduced mortality and length of stay in adults with community-acquired pneumonia: playing by the rules. , 2009, Archives of internal medicine.

[4]  J. Ramirez,et al.  Guidelines for empiric antimicrobial prescribing in community-acquired pneumonia. , 2004, Chest.

[5]  A D Oxman,et al.  Audit and feedback: effects on professional practice and health care outcomes. , 2003, The Cochrane database of systematic reviews.

[6]  Mary Ellen Kitler,et al.  European Respiratory Society , 2005, International Journal of Pharmaceutical Medicine.

[7]  J. Macfarlane,et al.  British Thoracic Society guidelines for the management of community acquired pneumonia in adults: update 2009 , 2009 .

[8]  D. Battleman,et al.  Rapid antibiotic delivery and appropriate antibiotic selection reduce length of hospital stay of patients with community-acquired pneumonia: link between quality of care and resource utilization. , 2002, Archives of internal medicine.

[9]  N. Dean,et al.  Improved clinical outcomes with utilization of a community-acquired pneumonia guideline. , 2006, Chest.

[10]  D. Paterson,et al.  Should third‐generation cephalosporins be the empirical treatment of choice for severe community‐acquired pneumonia in adults? , 1998, The Medical journal of Australia.

[11]  J. Collin,et al.  Quantitative evaluation of a clinical intervention aimed at changing prescriber behaviour in response to new guidelines. , 2009, Journal of evaluation in clinical practice.

[12]  W. Lim,et al.  Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study , 2003, Thorax.

[13]  M. Fine,et al.  A prediction rule to identify low-risk patients with community-acquired pneumonia. , 1997, The New England journal of medicine.

[14]  S. Tett,et al.  Drug utilization review across jurisdictions – a reality or still a distant dream? , 2006, European Journal of Clinical Pharmacology.

[15]  S. Bowler,et al.  Effect of a simple educational intervention on the hospital management of community‐acquired pneumonia , 2007, Respirology.

[16]  R. Ruffin,et al.  Community acquired pneumonia. A perspective for general practice. , 2000, Australian family physician.

[17]  M. Niederman,et al.  Adherence to guidelines’ empirical antibiotic recommendations and community-acquired pneumonia outcome , 2008, European Respiratory Journal.

[18]  John G. Bartlett,et al.  Update of Practice Guidelines for the Management of Community-Acquired Pneumonia in Immunocompetent Adults , 2003, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[19]  Kylie L Easton,et al.  Empiric management of community‐acquired pneumonia in Australian emergency departments , 2005, The Medical journal of Australia.

[20]  J. Turnidge,et al.  3: Community‐acquired pneumonia , 2002, The Medical journal of Australia.

[21]  J. Ramirez,et al.  Improving outcomes in elderly patients with community-acquired pneumonia by adhering to national guidelines: Community-Acquired Pneumonia Organization International cohort study results. , 2009, Archives of internal medicine.

[22]  E. Halm,et al.  Limited impact of a multicenter intervention to improve the quality and efficiency of pneumonia care. , 2004, Chest.

[23]  D. Brookman.  Therapeutic Guidelines: Antibiotic. Version 12. , 2003 .

[24]  M. Fine,et al.  Guidelines for the management of adults with community-acquired pneumonia. Diagnosis, assessment of severity, antimicrobial therapy, and prevention. , 2001, American journal of respiratory and critical care medicine.

[25]  Stephen B. Soumerai,et al.  Improving Drug-Therapy Decisions through Educational Outreach , 1983 .

[26]  P. Cuddy,et al.  The rational clinical examination. Is this patient allergic to penicillin? An evidence-based analysis of the likelihood of penicillin allergy. , 2001, JAMA.

[27]  S. Kirsa,et al.  SHPA Standards of Practice for Drug Use Evaluation in Australian Hospitals: SHPA Committee of Specialty Practice in Drug Use Evaluation , 2004 .

[28]  S B Soumerai,et al.  Principles of educational outreach ('academic detailing') to improve clinical decision making. , 1990, JAMA.

[29]  A. Didier,et al.  Guidelines for management of adult community-acquired lower respiratory tract infections , 1998 .

[30]  C. Frei,et al.  Guideline-concordant antibiotic use and survival among patients with community-acquired pneumonia admitted to the intensive care unit. , 2010, Clinical therapeutics.

[31]  L. Weekes,et al.  National Prescribing Service: creating an implementation arm for national medicines policy. , 2005, British journal of clinical pharmacology.

[32]  D. Singer,et al.  Understanding physician adherence with a pneumonia practice guideline: effects of patient, system, and physician factors. , 2000, Archives of internal medicine.