Team Membership

Stephanie Detterline, MD Mary E. Altier, MSN, RN

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

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

PNEUMONIAPNEUMONIA

Opportunity for ImprovementOpportunity for Improvement

To improve the rates of quality measures specific to the Pneumonia Core measure:

• Antibiotic Timing• Appropriate Antibiotic Administered• Blood Culture Collection • Oxygen Level Assessment• Pneumococcal Vaccination: > 65 years • Influenza Vaccination: > 50 years• Adult Smoking Cessation Counseling

GoalsGoals• Initial antibiotic administered

within 4 hours of arrival at hospital

• Appropriate antibiotic administered

• Blood cultures collected prior to initial antibiotic dose

• Oxygen level assessed within initial 24 hours of arrival

• 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

ED Plan

• ED QI Project: “Pneumonia Core Measure: 4 hours to initial antibiotic.”

• ED special observation unit opened 9/2006 • Creation of quarterly “dashboard” report

card for ED highlighting measures that impact their practice. Fall 2006

• Creation of individual ED physician performance reports. Fall 2006

Plan• Appropriate antibiotics in

ED Omnicell and as floorstock.

• Daily rounds on all in-patient pneumonia patients

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

• Pneumovax/Influenza in-service to inpatient units

• Promotion of ambulatory walk-in clinics

• Smoking cessation counseling verbiage added to EPIC discharge navigator

• Participation in the UHC Core Measures Networking Collaborative 2006-2007

• Participation in Patient Safety Fair: “In-patient Vaccinations” March 2007

Per

cen

tCore Measures

Pneumonia Patients Composite Score

Month

UCL = 86.5

Mean = 52.2

LCL = 17.9

Apr 200

5 (n

=13)

May

200

5 (n

=17)

Jun 2

005

(n=1

1)

Jul 2

005

(n=2

0)

Aug 200

5 (n

=14)

Sep 2

005

(n=1

5)

Oct 2

005

(n=1

7)

Nov 20

05 (n

=20)

Dec 2

005

(n=2

1)

Jan 2

006

(n=2

4)

Feb 2

006

(n=2

7)

Mar

200

6 (n

=23)

Apr 200

6 (n

=27)

May

200

6 (n

=17)

Jun 2

006

(n=2

1)

Jul 2

006

(n=1

4)

Aug 200

6 (n

=22)

Sep 2

006

(n=2

0)

20

40

60

80

100

Definition: Number of pneumonia patients receiving 100% of indicated care / all pneumonia patients

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

Analysis: LUMC performance is above the UHC median.

Discharge form updated to include smoking cessation recommendations and increased nurse audits

Definition: Pneumonia patients who had an assessment of arterial oxygenation by arterial blood gas measurement or pulse oximetry within 24 hours prior to or after arrival at the hospital / All pneumonia patients.

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

Analysis: LUMC pneumonia patients receive oxygen assessment as a standard of practice. LUMC performance is stable with an average of 100%, meeting the stretch goal.

Stretch Goal is based on Senior Management Critical Success Factors for FY07

Per

cen

tCore Measures

Pneumonia Patients Receiving Oxygen Assessment

Month

Stretch Goal = 100%

Apr 200

5 (n

=13)

May

200

5 (n

=17)

Jun 2

005

(n=1

1)

Jul 2

005

(n=1

9)

Aug 200

5 (n

=14)

Sep 2

005

(n=1

5)

Oct 2

005

(n=1

7)

Nov 20

05 (n

=19)

Dec 2

005

(n=2

1)

Jan 2

006

(n=2

4)

Feb 2

006

(n=2

7)

Mar

200

6 (n

=23)

Apr 200

6 (n

=27)

May

200

6 (n

=17)

Jun 2

006

(n=2

0)

Jul 2

006

(n=1

4)

Aug 200

6 (n

=21)

Sep 2

006

(n=1

9)

100.00

100.05

100.10

100.15

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 is consistent at 93%.

Stretch Goal is based on Senior Management Critical Success Factors for FY07

Per

cen

tCore Measures

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

Month

UCL = 131.2

Mean = 93.2

LCL = 55.2

Jul 2

005

(n=4

)

Aug 200

5 (n

=2)

Sep 2

005

(n=4

)

Oct 2

005

(n=3

)

Nov 20

05 (n

=4)

Dec 2

005

(n=3

)

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=4

)

20

40

60

80

100

120

140

160

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 92%.

Per

cen

tCore Measures

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

Month

UCL = 112.5

Mean = 91.9

LCL = 71.4

Jul 2

005

(n=1

6)

Aug 200

5 (n

=13)

Sep 2

005

(n=1

4)

Oct 2

005

(n=1

6)

Nov 20

05 (n

=16)

Dec 2

005

(n=1

9)

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

=15)

Sep 2

006

(n=1

4)

70

80

90

100

110

Definition: Pneumonia patients who receive initial antibiotic within 4 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 consistent at 66%. A team of physicians and nurses are actively working to ensure that all patients with pneumonia receive initial antibiotics within 4 hours of arrival.

Stretch Goal is based on Senior Management Critical Success Factors for FY07

Per

cen

tCore Measures

Pneumonia Patients Receiving Initial Antibiotic within 4 Hours of Hospital Arrival

Month

UCL = 105.6

Mean = 66.1

LCL = 26.6

Stretch Goal = 80%

Apr 200

5 (n

=10)

May

200

5 (n

=10)

Jun 2

005

(n=9

)

Jul 2

005

(n=1

5)

Aug 200

5 (n

=10)

Sep 2

005

(n=8

)

Oct 2

005

(n=1

1)

Nov 20

05 (n

=16)

Dec 2

005

(n=1

7)

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

=13)

Sep 2

006

(n=1

5)

20

40

60

80

100

120

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 is consistently at 92%.

Stretch Goal is based on Senior Management Critical Success Factors for FY07

Per

cen

tCore Measures

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

Month

UCL = 120.8

Mean = 91.7

LCL = 62.6

Stretch Goal = 95%

Apr 200

5 (n

=7)

May

200

5 (n

=7)

Jun 2

005

(n=6

)

Jul 2

005

(n=8

)

Aug 200

5 (n

=7)

Sep 2

005

(n=5

)

Oct 2

005

(n=1

0)

Nov 20

05 (n

=7)

Dec 2

005

(n=8

)

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

=5)

Sep 2

006

(n=1

0)

40

60

80

100

120

140

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 is at 83%. Interventions have been implemented into the electronic medical record to ensure all patients receive pneumococcal vaccination when appropriate.

Stretch Goal is based on Senior Management Critical Success Factors for FY07

Per

cen

tCore Measures

Pneumonia Patients Receiving Pneumococcal Vaccination

Month

UCL = 119.5

Mean = 82.5

LCL = 45.4

Stretch Goal = 90%

Apr 200

5 (n

=8)

May

200

5 (n

=11)

Jun 2

005

(n=7

)

Jul 2

005

(n=7

)

Aug 200

5 (n

=10)

Sep 2

005

(n=5

)

Oct 2

005

(n=7

)

Nov 20

05 (n

=6)

Dec 2

005

(n=1

1)

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=9

)

40

60

80

100

120

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 inconsistent but recently appears promising. Since April 2005, 69% of eligible pneumonia patients who smoke have received counseling.

Stretch Goal is based on Senior Management Critical Success Factors for FY07

Discharge form updated to include smoking cessation

recommendations with increased nurse audits

Per

cen

tCore Measures

Smokers Receiving Smoking Cessation Advice for Pneumonia Patients

Month

UCL = 142.1

Mean = 69.2

LCL = 0.0

Stretch Goal = 95%

Apr 200

5 (n

=3)

May

200

5 (n

=2)

Jun 2

005

(n=4

)

Jul 2

005

(n=5

)

Aug 200

5 (n

=2)

Sep 2

005

(n=2

)

Oct 2

005

(n=2

)

Nov 20

05 (n

=3)

Dec 2

005

(n=2

)

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=4

)

0

20

40

60

80

100

120

140

160

Next Steps

• Ed initiative: use of ancillary room in ED waiting room to obtain blood cultures and send patient for chest x-ray.

• Presentation at University Healthsystem Consortium as “Top Performer: Pneumonia Core Measure” May 2007