The trusted source for
healthcare information and
By Brenda S. Holland, MSN, RN
Department of Care Management
Alamance Regional Medical Center
In today's cost-conscious environment, the cost of health care is spiraling out of control. At the same time, society is demanding better health care, scientists are searching for more cures, and the government is trying to control costs. To compete in this health care environment, hospitals and health care professionals must develop a centrally organized process of care based on research and analysis to help set priorities for this new and ever-changing health care environment.
To adapt, Alamance Regional Medical Center in Burlington, NC, began developing the Pneumonia CareWay Sept. 27, 1995. It was implemented July 6, 1996. The Pneumonia CareWay focus group that developed the multidisciplinary process included:
• a pulmonologist;
• family medicine;
• medical-surgical nurse;
• emergency room nurse;
• finance department;
• infection control nurse;
• cardiopulmonary department;
• CareWay's coordinator.
Literature indicates that pneumonia was the sixth leading cause of death in the United States and the No. 1 cause of death from infectious diseases in 1993. Among patients with community acquired pneumonia requiring hospitalization, mortality rates approached 25% during this period. Potential adverse outcomes for this illness include increased length of stay and death. These two outcomes alone would indicate an increase in hospital charges and resource utilization.
Because pneumonia is not a reportable disease, exact information about its incidence is not available, but it is estimated that up to 4 million cases occur annually. Both the American and British Thoracic societies published guidelines in 1993 that suggest that patients who receive adequate sputum and blood cultures before antibiotic therapy and for whom the appropriate antibiotic is initiated within four hours of admission have significantly better outcomes.
The Pneumonia CareWay is the result of a 10-month-long effort to examine the initial care provided to all patients admitted with the diagnosis of pneumonia, or DRG 89. Patients are placed on the CareWay while in the emergency room department. This factor alone decreased the time frame for obtaining sputum and blood cultures. Since the blood and sputum cultures are collected earlier, the average time from admission to the emergency room and administration of antibiotics is four hours and six minutes. The mean average length of stay for this patient population decreased from nine days to 4.5 days. Quality care with cost-effective measures benefited both the hospital and patient on the Pneumonia CareWay.
In 1997, the multidisciplinary team reviewed all data the initial Pneumonia CareWay had provided. It reviewed current practices and reimbursement issues and decided a five-day stay would provide quality care while reducing costs for patients and payers. The updated Pneumonia CareWay was implemented September 1997.
CareWay revisions must be a continuous process if a hospital is to survive. The Pneumonia CareWay is no exception. This multidisciplinary team met again Feb. 2, 1999, to re-examine data analysis, literature, and reimbursement information. Literature revealed that these four quality indicators were effective in gaining positive outcomes:
• antibiotics within four hours of admission;
• blood culture within 24 hours of arrival;
• blood culture before antibiotic was given;
• oxygenation assessed within 24 hours of arrival.
Two indicators are being added to the list of positive outcomes and quality care for the Pneumonia CareWay patients:
• inpatients with pneumonia screened for or given influenza vaccination;
• inpatients with pneumonia screened for or given pneumococcal vaccination.
Pneumonia and influenza cause substantial morbidity and mortality for our older patients. These last two quality indicators present opportunities for improvement for our Medicare patient population, which constitutes approximately 46% of our payer mix. Future improvements in quality outcome indicators and cost effectiveness likely will stem from continued review of research-based literature and analysis of the Pneumonia CareWay variance information.