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PNEUMONIA

PNEUMONIA. Team Membership: Susan A . Tuzik, MS, RN Rose Lach, Administrative Director Clinical Departments : Emergency Medical Services, General Medicine, Cardiac Services

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PNEUMONIA

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  1. PNEUMONIA Team Membership: Susan A . Tuzik, MS, RN Rose 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

  2. 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

  3. 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

  4. 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 Goals Confidential: For Quality Improvement Purposes Only

  5. 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 Plan Confidential: For Quality Improvement Purposes Only

  6. 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

  7. 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

  8. Pneumonia Patients Receiving Blood Cultures in the Emergency Dept Before First Antibiotic 120 UCL = 111.0 Mean = 93% 100 80 LCL = 75.1 60 ED Standing Orders based on symptoms and age to allow RN to deliver specific antibiotics, draw blood culture, and order chest x-ray Percent ED Standing Orders based on guidelines that allow RN to order chest x-ray, blood culture & deliver first dose antibiotic 40 20 Confidential: For Quality Improvement Purposes Only 0 Aug 2007 (n=7) Jul 2006 (n=11) Jul 2007 (n=19) Apr 2006 (n=20) Apr 2007 (n=19) Jun 2006 (n=12) Jun 2007 (n=11) Jan 2006 (n=20) Jan 2007 (n=26) Jan 2008 (n=23) Feb 2006 (n=22) Mar 2006 (n=16) Oct 2006 (n=15) Feb 2007 (n=15) Mar 2007 (n=34) Oct 2007 (n=13) Feb 2008 (n=18) Mar 2008 (n=28) Aug 2006 (n=16) Nov 2006 (n=14) Nov 2007 (n=18) May 2006 (n=12) Sep 2006 (n=16) May 2007 (n=17) Sep 2007 (n=30) Dec 2006 (n=20) Dec 2007 (n=16) Month 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%.

  9. Pneumonia Patients Receiving Initial Antibiotic within 6 Hours of Hospital Arrival 140 120 UCL = 111.2 UCL = 111.8 Mean = 89% 100 Mean = 79% 80 LCL = 66.1 Percent 60 LCL = 47.7 40 ED Standing Orders based on guidelines that allow RN to order chest x-ray, blood culture & deliver first dose antibiotic 20 0 Jun 2007 (n=9) Aug 2007 (n=4) Jul 2006 (n=10) Jul 2007 (n=18) Apr 2006 (n=19) May 2006 (n=9) Apr 2007 (n=16) Oct 2006 (n=17) Oct 2007 (n=15) Jun 2006 (n=13) Jan 2006 (n=17) Jan 2007 (n=24) Jan 2008 (n=18) Feb 2006 (n=15) Mar 2006 (n=16) Feb 2007 (n=14) Mar 2007 (n=25) Feb 2008 (n=17) Mar 2008 (n=27) Aug 2006 (n=14) Nov 2006 (n=13) Nov 2007 (n=14) Sep 2006 (n=19) May 2007 (n=12) Sep 2007 (n=22) Dec 2006 (n=13) Dec 2007 (n=19) Month 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. Confidential: For Quality Improvement Purposes Only

  10. Pneumonia non-ICU Patients Receiving Initial Antibiotic Selection Consistent with Current Guidelines 140 120 UCL = 118.5 UCL = 115.8 Mean = 92% Mean = 97% 100 LCL = 78.3 80 Percent LCL = 65.2 60 40 ED Standing Orders based on guidelines that allow RN to order chest x-ray, blood culture & deliver first dose antibiotic 20 0 Jul 2006 (n=3) Jul 2007 (n=5) Apr 2007 (n=7) Jun 2007 (n=5) Jan 2008 (n=4) Jun 2006 (n=9) Oct 2007 (n=6) Aug 2006 (n=6) Aug 2007 (n=1) Dec 2006 (n=8) Sep 2007 (n=9) Dec 2007 (n=9) Feb 2008 (n=5) Nov 2006 (n=5) Nov 2007 (n=6) Apr 2006 (n=10) May 2006 (n=6) May 2007 (n=6) Jan 2006 (n=11) Jan 2007 (n=18) Feb 2006 (n=12) Mar 2006 (n=14) Oct 2006 (n=10) Feb 2007 (n=10) Mar 2007 (n=17) Mar 2008 (n=12) Sep 2006 (n=11) Month 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. Confidential: For Quality Improvement Purposes Only

  11. Pneumonia Patients Receiving Blood Cultures Within 24 Hours for those Admitted to the ICU Within 24 Hours of Hospital Arrival 160 140 120 UCL = 124.7 100 Mean = 94% 80 Percent LCL = 64.0 60 40 20 0 Jul 2006 (n=3) Jul 2007 (n=8) Apr 2006 (n=7) Apr 2007 (n=7) Jun 2006 (n=4) Jun 2007 (n=5) Jan 2006 (n=8) Jan 2007 (n=5) Jan 2008 (n=8) Oct 2006 (n=3) Oct 2007 (n=6) Aug 2006 (n=4) Aug 2007 (n=5) Sep 2006 (n=6) Nov 2006 (n=5) Dec 2006 (n=7) Sep 2007 (n=7) Nov 2007 (n=4) Dec 2007 (n=5) Mar 2006 (n=1) Mar 2007 (n=8) Mar 2008 (n=5) Feb 2006 (n=3) Feb 2007 (n=5) Feb 2008 (n=5) May 2006 (n=5) May 2007 (n=2) Month 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. Confidential: For Quality Improvement Purposes Only

  12. Pneumonia Patients Receiving Pneumococcal Vaccination 120 UCL = 112.9 100 80 Mean = 82% 60 Percent LCL = 51.8 40 Nursing Go-Live Pneumonia team transition 20 0 Jul 2006 (n=7) Jun 2006 (n=8) Jun 2007 (n=8) Aug 2006 (n=9) Aug 2007 (n=6) Jul 2007 (n=16) Feb 2008 (n=9) Apr 2006 (n=15) Apr 2007 (n=16) Oct 2006 (n=17) Oct 2007 (n=11) Jan 2006 (n=11) Jan 2007 (n=24) Jan 2008 (n=13) Feb 2006 (n=16) Mar 2006 (n=13) Feb 2007 (n=16) Mar 2007 (n=24) Mar 2008 (n=28) Nov 2006 (n=10) Nov 2007 (n=15) May 2006 (n=11) Sep 2006 (n=11) May 2007 (n=12) Sep 2007 (n=20) Dec 2006 (n=16) Dec 2007 (n=17) Month 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. Confidential: For Quality Improvement Purposes Only

  13. Pneumonia Patients Receiving Influenza Vaccination UCL = 97.1 100 80 Mean = 67% 60 Percent 40 LCL = 36.8 Nursing Go-Live Pneumonia team transition 20 0 Jan 2006 (n=16) Jan 2007 (n=36) Jan 2008 (n=22) Oct 2007 (n=16) Nov 2006 (n=19) Nov 2007 (n=22) Feb 2006 (n=19) Dec 2006 (n=19) Feb 2007 (n=17) Dec 2007 (n=23) Feb 2008 (n=16) Mar 2008 (n=38) Month 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. Confidential: For Quality Improvement Purposes Only

  14. Smokers Receiving Smoking Cessation Advice for Pneumonia Patients 160 140 120 UCL = 126.1 Mean = 93% 100 80 Percent LCL = 60.0 60 40 20 0 Jul 2006 (n=2) Jul 2007 (n=9) Apr 2006 (n=2) Apr 2007 (n=6) Jun 2006 (n=4) Jun 2007 (n=1) Jan 2006 (n=9) Jan 2007 (n=8) Jan 2008 (n=5) Oct 2006 (n=8) Oct 2007 (n=4) Aug 2006 (n=6) Aug 2007 (n=7) Sep 2006 (n=5) Nov 2006 (n=4) Dec 2006 (n=3) Sep 2007 (n=7) Nov 2007 (n=4) Dec 2007 (n=7) Mar 2006 (n=3) Mar 2007 (n=9) Mar 2008 (n=5) Feb 2006 (n=5) Feb 2007 (n=5) Feb 2008 (n=7) May 2006 (n=5) May 2007 (n=4) Month 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. Confidential: For Quality Improvement Purposes Only

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