Flowcharts help medical center boost pneumonia outcomes

Guidelines reduced variation

Last year, Advocate Christ Medical Center at Hope Children’s Hospital in Chicago decided to take a snapshot of how it was treating pneumonia patients. What it discovered, reports Sharon Otten, a care management utilization review specialist, is that 87% of the patients diagnosed with pneumonia were entering the system through its emergency rooms. However, there was very wide variation in the cost per case and in the use of antibiotics.

Physicians each had their own "boutique package," which they felt was the best way to treat patients, says Letisha Losurdo, manager of performance improvement at Advocate. "We didn’t have a goal out there for people to really work toward and achieve."

According to Otten, the key indicators were not length of stay or cost per case, however. "Our focus was really on improving the clinical care for the patient," she says.

Because of the variances identified, the hospital decided to look more closely at treatment at the site level. Advocate consists of eight hospitals, a home care agency, and several clinics. Christ Hospital, which is part of that system, has 662 licensed beds. It is a Level I trauma center, a Level III perinatal center, and a not-for-profit teaching facility.

Otten says the hospital’s case management model has two primary focuses — care coordination and social services. Twenty-seven full-time nurses are devoted to care coordination and utilization review, while 16 social workers perform counseling and discharge planning. The caseload for the care coordinators is about 22 to 29 cases, while the caseload for social workers is between 30 and 50. For the most part, they are unit-based, Otten says.

The average cost per case for pneumonia was roughly $5,500 in 1998 but rose steadily to almost $6,400 per case by 2001. Meanwhile, pneumonia length of stay gradually declined from six days in 1998 to five days by 2001. That led Advocate to question if there was an opportunity for improvement. "Our cost per case was rising despite the decrease in the length of stay," Otten says. "We really felt that we needed to drill down to the case level to see what was going on."

According to Losurdo, the hospital discovered it was doing a good job of processing patients through the system but that the process was cluttered by steps that could be eliminated to make care more efficient. "We also found that some of our patients could benefit from screening," says Losurdo. She says the hospital discovered that not all cases required aggressive antibiotic therapy and that some patients could benefit from an outpatient regimen.

In short, it became apparent that while the hospital was doing a good job of treating pneumonia, it was not working efficiently as a team in treating those patients, Losurdo says. "We weren’t connecting the care, monitoring the care, and really collaborating through the continuum," she says.

According to Losurdo, the majority of patients — between 85% and 95% — entered the system through the emergency room, where they were evaluated and diagnosed with pneumonia. Advocate decided to focus its attention on appropriate selection and timing of antibiotics and the switch from intravenous therapy antibiotics to oral antibiotics.

Reducing variation

Losurdo says the best way to eliminate variation is to implement standards or guidelines for people to follow. Advocate researched the literature to examine those guidelines and sought out local physician experts to improve patient outcomes while reducing the length of stay and cost per case.

The hospital also initiated performance improvement using a flowchart, which Losurdo says is the ideal tool for this process because it helps illustrate the components of care. "It helped us to see where we had delays in our process and where we have redundant steps, and capitalize on opportunities for improvement," she explains.

If the antibiotics were administered in the emergency department, that process was expedited. Patients were assigned to the medical unit, where nurses again assessed the patient. "We looked at the assessment of the patient, determined if the patient was on the appropriate antibiotics, and observed the response to treatment," she says.

During that process, the team looked at the possibility of switching from intravenous therapy antibiotics to oral antibiotics. The team also examined variations in practice among physicians and found that it was not taking full advantage of guidelines and recommendations for the treatment of pneumonia.

Losurdo says the hospital used the flowchart to gauge treatment and examine how the team functioned. While the right resources typically were involved, she says there was limited collaboration among the various disciplines. "Everybody was on their own mission out to accomplish their component of care," she says. "We were handing off treatment to each other and not collaborating over that treatment."

According to Losurdo, the assessment of the flowchart revealed opportunities for improvement along with specific actions. For example, the hospital added the use of admissions screening and risk stratification criteria to make sure it was identifying patients who required aggressive antibiotic therapy as well as those who could be treated at the outpatient level.

Losurdo says one critical area that was examined was the recommended drug of choice. "We published antibiotic guidelines for use and recommendations for IV-to-oral switch times," she reports. "We looked at the data and wanted to capitalize on the information that we had."

Because the vast majority of patients entered the system through the emergency department, a goal was established to administer the first dose of antibiotic within the first four hours of care.

Team thinks outside the box

In looking at the long-term goals for pneumonia, Losurdo says Advocate wanted to incorporate some "out-of-the-box" thinking. "We looked at what it would do to our larger picture and how it would really help us to decrease mortality and morbidity rates and what we could do to optimize our ability to manage our own beds," she says.

In addition to developing guidelines to standardize treatment, the hospital turned to professionals in its health information management department to help enhance and improve documentation and coding for pneumonia patients. "This had an impact on our ability to track and monitor the patients over time," says Losurdo.

Advocate uses a proprietary system for its physicians called Care Net. Some of the tools for the pneumonia initiatives then were linked to that system to enable physicians to access resources.

The data package included baseline data, which were used to plot progress on a monthly basis. "A consulting group was used to help collect the baseline data," she adds. "They helped us to develop the data collection tool that would be used by all of the Advocate sites so that we would be able to compare data and initiatives and progress over time," she explains.

The hospital reviewed benchmark opportunities and made a plan to share data and share success stories. "What other sites had found to be successful hits in their projects, we shared and implemented within our own sites as well," she says.

While the site initiatives for the system were being established, a number of questions were considered: How are patients identified and diagnosed? What practices should be targeted related to pneumonia? What antibiotics would be selected as the antibiotics of choice? How could the first dose be administered within that four-hour window of care?

The systemwide initiative established the framework for the site objectives, Losurdo says. "To accomplish these site objectives, we needed to make sure that we had the right team players," she says. "We had the right representation, but we needed to refresh our team to really drive actions forward."

The site teams and the system team both were led by physicians, and the physician who led the system initiative was the "site champion," she says. "We had the best of the best."

The team comprised physician representation from internal medicine, family practice, pulmonary medicine, and the emergency department. Also included were representatives from the resident health staff, nursing, epidemiology, and care management. Ancillary resources, such as labs, health information management professionals, social services, and pharmacists also were included.

Losurdo says performance improvement assisted the team by bringing structure to the process and by being able to analyze the data.

Once the objectives were established, the hospital was able to implement specific actions to drive the initiative forward in the most aggressive fashion possible, according to Losurdo. To accomplish that, it used an action plan to identify specific goals, determine who was accountable for those goals, and establish target dates.

"The beauty of it is that our physician leader actually used the action plan," Losurdo says. "This is music to a performance improvement person’s heart, because these are tools that really help us and charge us in the mode of accountability."

Educating physicians and staff

According to Losurdo, the first key component was education, which raised the level of awareness and knowledge related to the pneumonia initiative.

"Our tools guided our approach to care and helped to raise the levels of awareness of our pneumonia project," she says. "The more awareness you have, the more likely you are to have people to continue to buy in and to keep your initiative charged."

According to Losurdo, the team used a variety of tools to help get the information in front of people, including posters in patient units, physician lounges, resident lounges, and even bathrooms. The team used resources from the Illinois Foundation for Quality Healthcare, the local quality improvement organization.

Another tool used was a white card that clipped to a name badge that served as a reminder of the three key initiatives: the selection of antibiotics, the timing, and the switch timing.

In addition, the team used a trifold that easily fit in a pocket. "We furnished these to our physicians, our house staff, and to our care managers so that they could be pulled out and referenced, so that we were constantly reinforcing the use of screening criteria and risk stratification," she explains.

Two additional tools also were very important, says Losurdo: guidelines for the use of antibiotics, and a surveillance tool. The guidelines were put on the front of the patient chart and used as a reminder for physicians to help reinforce the use of selected antibiotics, the timing of the antibiotics, and the IV-to-oral switch time.

The surveillance tool was used primarily by care managers and epidemiology team members to conduct concurrent case monitoring of pneumonia patients. "We considered this to be a living, breathing, working document," she says. "Most importantly, what this tool did for us was to prompt an immediate interaction and intervention with the attending physicians."

Losurdo says this process helped pull in all of the key pieces involved in pneumonia care to provide a visual picture of that care. She says that visual picture was used to drive the ongoing assessment of patients and move them toward the switch time.

"We tried care paths in the past and, to be honest, they didn’t work," Otten says. "Physicians viewed it as a nursing document; nurses were all too busy to use it; and it really wasn’t an active piece of information for anybody."

Advocate did not attempt to reinvent the wheel, says Otten. "What we did was to spin it a little differently, beginning with the point of entry." She says that included criteria for admission and risk stratification in addition to developing a treatment plan that included the timing and selection of the appropriate antibiotics.

According to Losurdo, the flowchart is central to the process. The clinical evaluation and screening and the risk stratification is the first decision point. If a patient falls into risk class one or two, the hospital considers initiating an oral antibiotic and discharging the patient.

If the patient falls into risk classification three, four, or five, the hospital considers an inpatient approach with an antibiotic ordered in the emergency department based upon its published selection of antibiotics. "We look at the first dose to be given while the patient was in the emergency department and then the transferring of care of the patient to the inpatient unit," says Losurdo.

Losurdo says this is where the interdisciplinary team came into play and changed the approach to patient care through collaboration among epidemiology, care management, the attending physicians, social workers, and pharmacists.

According to Losurdo, there was a bonus to the initiative. "Not only did we accomplish our main goals, but we also looked at the impact that it would have on our ability to better recognize our opportunities for lengths of stay and cost reduction," she says. The team recognized there might still be "an antibiotic loop" in the flowchart, but when that occurs now, it is due to a culture-resistant organism.

Losurdo emphasizes that the composition of the team did not change between 2001 and 2002. "What changed was our team dynamics and how we used the people that comprised the team," she explains. "The team achieved success through ongoing communication and collaboration."

Collaboration included epidemiology

Also key to the process were the resources of the epidemiology nursing team, which collaborated with the clinical bed management team. Losurdo says epidemiology began sitting in on bed management meetings in the mornings so that they could identify the patients who were admitted through the emergency department and follow them at the unit level. This had a major effect, she says.

Epidemiology also collaborated with care management and the attending physicians. "Care management worked closely with our physicians, with epidemiology, and with our pharmacy resources to assess care and look for the opportunity to target that IV-to-oral switch time," adds Losurdo.

In addition, social services now is in a more optimal position to plan for the patient’s discharge and any needs that patients or their families might have, says Losurdo. "This had a huge impact on our ability to be efficient," she says. Pharmacy worked not only to guide the switch time, but also was central to ensuring the most appropriate oral antibiotic for the patient, she adds. 

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