Critical Path Network

Program targets pneumonia quality measures

Standardizing care increases cost-effectiveness

A comprehensive system to ensure that patients with pneumonia receive recommended care resulted in a significant increase in quality measure scores at Mission Hospital in Asheville, NC.

"We wanted to improve the quality and cost-effectiveness of care for pneumonia patients and to develop a single process so that patients receive the same care, no matter which of our two hospital buildings they were in and what floor they were on. This resulted in a reduction in length of stay and cost per case as well as increasing our scores on the core measures," says Andrea Yontz, RN, BSN, performance improvement specialist and team leader of the multidisciplinary team that developed the initiative and continues to monitor the hospital's progress.

"Our process is still changing and growing but we do know that standardization makes the work flow more efficient and increases compliance," she adds.

Multidisciplinary team

The team includes physicians, a pharmacist, an ED nurse, a respiratory therapist, a pulmonary educator, representatives from pulmonology, and case managers.

"The multidisciplinary team relied heavily on case management during the time we were developing the initiative and during implementation. Case managers are crucial in ensuring that patients get what they need," Yontz says.

The team began by breaking down the pneumonia core measures and working on them piece by piece.

"In the beginning, we broke into groups with each working on one component of the quality measures, but that didn't work well. We found it better to break it down into sections and deal with each section individually," she says.

As each piece of the process was completed, the team educated the staff on the changes, and then gave it time to take effect. The performance improvement department conducted weekly chart reviews of all discharged pneumonia patients, looking for deficiencies.

"If it didn't work, we came back to the drawing board. If it looked like it would work, we moved on to the next piece," she says.

Yearlong implementation process

It took about a year to develop all of the initiatives and implement them. The team spent the next year examining the results, fine-tuning the program, and filling in the gaps.

For instance, initially, there was no process in place to give smoking cessation education to patients in the intensive care units.

"We are constantly updating and improving on our process. When the hospital system implemented the electronic medical record, we had to adapt it to an electronic process," Yontz says.

A major component of the initiative involved changing the patient flow system in the ED to ensure faster treatment of pneumonia patients.

Before the new protocol was put into place, pneumonia patients were triaged as being nonemergent. Now, pneumonia patients receive rapid treatment assessment by being triaged as "urgent."

"With the core measures, CMS has established the expectation that patients with indicators for possible pneumonia are diagnosed and receiving medication within four hours of arrival. When the emergency department was at capacity, some pneumonia patients weren't getting into a treatment bed within four hours," she says.

If patients have a certain set of symptoms that may indicate pneumonia, the triage nurse can order a chest X-ray so that when the ED physician sees the patient, he or she already has the results from one diagnostic tool in hand.

Initiated standing orders

Another change was to initiate standing orders for the emergency department staff and make supplies easily available.

"We made changes to the medication dispensing machine so appropriate antibiotics are available in the machine," Yontz says.

Now, when the physician orders the medication, the nurse can go to the machine and take it out immediately. The ED has dedicated lab staff who can draw the blood cultures in a timely manner.

"Everything is located in the emergency department and there is no need to wait for anything to be sent to another part of the hospital," Yontz says.

The team reviewed the standardized order sets for pneumonia patients and looked at ways to incorporate the core measures for pneumonia.

For instance, the team changed the orders to indicate that the first dose of antibiotic should be given as a stat dose to ensure that patients get the medication in a timely manner.

"If the antibiotic is ordered as a routine order, the pharmacist might not get to it right away. If it's a stat order, it gets top priority, and the patient gets the medication faster. We wanted to make sure that the patients got the right drugs and in a timely manner," Yontz says.

The case managers, physicians, and pharmacist reviewed the recommended medications for pneumonia and made them the default drugs on the order set.

"We developed the order set so the default is the best practice. The physicians can still write in something different when they complete the computerized order entry but they have the recommended medications in front of them," she says.

Ensure vaccinations up to date

Ensuring that pneumonia patients have current influenza and pneumonia vaccinations was one of the biggest challenges, Yontz reports.

The team just started a new process that recommends screening pneumonia patients for the vaccinations as an automatic part of the patient record. Physicians can opt out of the vaccination screening. Otherwise, the nurse determines if the patients have had the vaccinations, screens them for appropriateness, and administers the vaccinations if the patients consent.

"It works like a protocol. The nurse is able to give the vaccinations without physician orders if the physician doesn't opt out of the screening and if the patient consents," Yontz explains.

In the past, to assure compliance with the vaccination measures, the case manager would have to track down the physician and get the order.

"We hope this method will greatly increase our vaccination compliance and save time for the case managers," Yontz says.

Smoking cessation

When the team tackled the smoking cessation advice and counseling requirements, they knew that there was no way that the busy case managers would be able to find the time to give individual smoking cessation lessons to every patient.

The team came up with a plan to include smoking cessation education as part of the discharge instructions for every patient and to offer in-depth smoking cessation education to patients who are willing to learn.

"It doesn't matter if the patient is a newborn infant, has had a fractured hip or an appendectomy, they still receive the information. We include information on avoiding secondhand smoke, which is important for everyone," Yontz says.

The case managers are responsible for seeing that the quality measures are implemented and use a quality indicator sheet to ensure that patients get all the recommended care.

"Case managers are juggling multiple tasks and dealing with different regulations. This makes it easy for them to remember what needs to be done," she says.

Electronic checklist

As the hospital has moved to an electronic medical record, the checklist has been incorporated into the software system.

Educating the staff to change their typical routine has been a major component of the initiative, Yontz says.

The case managers have worked closely with the ED physicians and other ED clinicians on ways to improve care.

"Changing physician practice in the emergency department is tricky, and it didn't happen overnight. Our emergency department physician champion worked with the case managers to facilitate change in the emergency department. It was a matter of educating the emergency department physicians and RNs and changing the way we did things," Yontz says.

The team continues to monitor the hospital's performance and to make changes as necessary.

"There is a learning curve from all paper to electronic. As everybody was learning the new system, our scores went down somewhat, but they're back up now that people can use the electronic process," Yontz says.

Last year, the team noticed that the vaccination rates were dropping and drilled down to find the cause. Part was attributed to the shift from paper order sets to electronic order entry. The team also took the opportunity to educate new physicians and staff that it is appropriate and safe for hospitalized patients to receive pneumonia and influenza vaccines.

"You can't just assume everything is going to continue to go smoothly. You have to continually update and educate new staff or they'll fall into old habits," Yontz says.

(For more information, contact Andrea Yontz, RN, BSN, performance improvement specialist, Mission Hospital, e-mail: