ED leads the way in improvement on CAP care

Core measure compliance improves dramatically

The ED at Mercy Medical Center in Des Moines, IA, has played a central role in the dramatic improvement in hospitalwide compliance with The Joint Commission core measures for community acquired pneumonia (CAP).

The Six Sigma performance improvement project has decreased mortality rates from 6.7% in 2003 to 3.5% in 2006, or a 47.8% reduction, while reducing mean length of stay (LOS) from 5.9 days to 5.1 days and saving more than $300,000. To achieve these improvements, the staff raised compliance scores for each Joint Commission core measure for CAP to between 70% and 90%.

"Prior to this, our compliance had only been 40%," reports Karen Gamerdinger, RN, MSN, pulmonary case manager and one of the leaders of the initiative.

It was only logical that the ED spearhead this improvement, explains Neil Horning, MD, medical director of the pulmonary care improvement team, because four of the six Joint Commission core measures in place at the time were performed in the ED. The measures were:

  • oxygenation assessment within 24 hours (performed in the ED);
  • blood cultures before antibiotic dose (performed in the ED);
  • antibiotics within four hours of arrival at the hospital (performed in the ED);
  • antibiotic regimen consistent with guidelines (performed in the ED);
  • screening and administration of influenza and pneumococcal vaccine;
  • smoking cessation advice or counseling for those who smoke or did so in the previous year.

The "point person" in the ED was Jeri Babb, MSN, CCRN, CEN, director of emergency services. "With her assistance we were able to get data back more quickly, we moved faster, and we knew where we were and were not making improvement, what we should and should not be doing," Horning says.

Babb says she employed education and high visibility to get the staff engaged in the initiative and to keep them engaged. "In our monthly department meetings we discussed that this initiative would be taking place, and we have discussed it in each of our department meetings since then," she says.

Since the ongoing results are e-mailed to her by Gamerdinger, she can put a summary graph up on a screen to show the staff how they are doing. "If in the last month we have slipped in our performance, then I point that out," she explains.

High visibility is achieved through posters throughout the department and in the break room, as well as through a weekly newsletter that is distributed to the staff electronically and in printed form. "We use newsletter articles to report progress or to make reference to any changes with our pneumonia care," Babb notes.

Close interface a key to success

The ED interfaces very closely with the initiative leaders, says Babb, which is "one of our strengths." For example, she says, Gamerdinger and Horning regularly attend the department meetings. "Dr. Horning also comes to the ED physician meetings a couple of times a year," notes Babb.

When the staff reached its current high levels of performance, "they threw pizza parties for all of our shifts," she says.

Gamerdinger also values the close working relationship. "Having the medical director from the ED function as a process owner meant she was able to give timely feedback to the staff that were deficient," she says.

In addition, says Babb, as part of her professional development model for RN staff nurses, they take turns conducting the random chart audits. "Whoever wants to step forward gets credit," she explains. "They pull the charts, return the results to me, and I give them credit for their professional development ladder."

An educational follow-up

When staff members are found to have fallen short on compliance, the follow-up meeting is educational in nature, says Babb. "It is not punitive at all," she says. "No one comes to work planning not to do their best job."

Instead, she says, she lets the staff member look at the case and ask themselves which part it they "own" and what they could do better. "They are now much more aware [of what they should do], and communication between staff members has become a lot better," says Babb.

She herself has learned a lot, Babb says, and the information from this initiative has led to others. "For example, when I see deficiencies such as antibiotics not given within four hours, I've learned that most of those are walk-ins, and that the problem is throughput, not the nurse being too busy to hang an antibiotic," Babb explains. "So, when it comes to getting our scores even higher than the 90s, where they currently are, we know we need to globally look at throughput, which is what we are currently doing."


For more information on the improving core measure compliance in the ED, contact:

  • Jeri Babb, MSN, CCRN, CEN, Director of Emergency Services, Mercy Medical Center, Des Moines, IA. Phone: (515) 247-4070.
  • Karen Gamerdinger, RN, MSN, Pulmonary Case Manager, Mercy Medical Center, Des Moines, IA. Phone: (515) 643-2497.