Evaluation of a pneumonia practice guideline in an interventional trial
ABSTRACT There are few available data to define the medically necessary duration of stay for patients hospitalized with pneumonia. Therefore, we investigated the safety and effectiveness of a practice guideline that provided information about switching patients from parenteral to oral antimicrobials and early hospital discharge. The study was a prospective controlled study with an alternate month design. The practice guideline was studied in 146 "low-risk" pneumonia patients hospitalized during a 22-month period. Medical care consistent with the practice guideline occurred in 64% and 76% of patients during control and intervention periods, respectively (p=0.15). There were no differences in patient outcomes in the control and intervention groups when measured 1 mo after hospital discharge, including hospital readmission rates, health-related quality of life, and patient satisfaction. Explicit and implicit review revealed that 98.6% (95% confidence interval [CI]: 95.1%, 99.8%) of low-risk patients would not have benefited from continued hospitalization after the fourth hospital day. The 30-d survival rate of the low-risk pneumonia patients was 99.3% (95% CI: 96.2%, 100%) and patient outcomes appeared to be favorable compared with previously published values. We conclude that duration of hospital stay was frequently consistent with the practice guideline in both study groups, and patient outcomes remained unchanged. The guideline will require additional testing before it can be recommended for use.
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- "Stevenson 1997), managing nursing home–acquired pneumonia more efficiently (Dempsey 1995), improving triage to thrombolytic interval for acute myocardial infarction (Krall, Reese, and Donahue 1995), and doing more to meet the needs of cancer patients and their families (McCartney et al. 1997) • improving the coordination of in-hospital care by reducing EDto-floor admission time ( Jackson and Andrew 1996), improving communication among interdisciplinary staff (Shindollar, Castillo, and Buelow 1995), reducing time intervals for ED fast-track patients , and scheduling more time for patient contact with a physician before discharge (Fernandes and Christenson 1995; Fernandes, Price, and Christenson 1997) • changing the mix of in-hospital services by decreasing the frequency of episiotomies (Reynolds 1995), lowering the rates of cesarean sections (Myers and Gleicher 1988), switching from intravenous to oral medications for pneumonia patients (Weingarten et al. (1996) • reducing in-hospital complications from peritoneal dialysis (Dillon , Murphy, and Larson 1995), reducing catheter infections (Civetta , Hudson-Civetta, and Ball 1996; Richard-Smith and Buh 1995), and decreasing medication errors (Carey and Teeters 1995) "
ABSTRACT: The literature on continuous quality improvement (CQI) has produced some evidence, based on nonrandomized studies, that its clinical application can improve outcomes of care while reducing costs. Its effectiveness is enhanced by a nucleus of physician involvement, individual practitioner feedback, and a supportive organizational culture. The few randomized studies, however, suggest no impact of CQI on clinical outcomes and no evidence to date of organization-wide improvement in clinical performance. Further, most studies address misuse issues and avoid examining overuse or underuse of services. The clinical application of CQI is more likely to have a pervasive impact when it takes place within a supportive regulatory and competitive environment, when it is aligned with financial incentives, and when it is under the direction of an organizational leadership that is committed to integrating all aspects of the work.Milbank Quarterly 02/1998; 76(4):593-624, 510. DOI:10.1111/1468-0009.00107 · 3.38 Impact Factor
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ABSTRACT: Objective: To assess process and outcome mea-sures before and after a multifaceted intervention for patients hospitalized on the medical floor with community-acquired pneumonia (CAP). • Setting and participants: 1054 patients with CAP admitted to 12 acute care community hospitals from March 1998 to February 2000 (baseline, n = 517) and from October 2000 to March 2001 (postinter-vention, n = 437). • Intervention: Hospitals could select 1 or more of 4 tools (preprinted orders, care pathways, a clinical pathway development tool, and sticker reminders) and 2 improvement strategies (physician profiling/ performance reports and the Institute for Healthcare Improvement's [IHI] Rapid Cycle Methodology). Update meetings and conference calls were held periodically to promote collaboration among hospitals. • Measurements: Time (in hours) from patient triage to initiation of intravenous (IV) antibiotics, percent-age of patients who receive antibiotics within 8 hours and within 4 hours of triage, days from triage to conversion from IV to oral antibiotics, days of in-hospital observation after switch from IV to oral antibiotics, length of stay (LOS), and in-hospital mortality rate. • Results: Significant improvements were noted in the mean time to administration of first dose of IV antibi-otics (4.01 to 3.57 hours, P = 0.002), percentage of patients receiving antibiotics within 4 hours (67.9% to 75.9%, P = 0.001), mean days from triage to switch from IV to oral antibiotics (2.02 to 1.25 days, P < 0.001), and mean LOS (5.62 to 5.04 days, P = 0.006). • Conclusion: Certain CAP process and outcome measures improved after the multicenter interven-tion. A controlled study is needed to verify that this type of intervention can result in improvements in antibiotic timing and LOS.