Pneumonia management

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Pneumonia management is an important topic and challenge for many organizations. The HMCwiki is a forum that allows you and others to collaborate on important issues surrounding this topic.

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Background information

Pneumonia is one of the most common inpatient medical diagnoses in the United States today. It comprises approximately 2.5% of all admissions.

Since 2005, pneumonia has been included as one of the mandatory reportable indicators (CMS & JCAHO Core Measures). With the reporting results of patient outcomes by hospital through public databases, and theoretically, payers being able to research the same results, effective cost and clinical management of pneumonia patients has moved front and center into the minds of clinicians and administrators.

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Issues in managing Pneumonia

Hospitals often struggle with how to effectively manage the care of pneumonia patients. Many use established protocols or care maps to guide physicians and care givers in how to achieve a good patient outcomes while controlling utilization of nursing and ancillary resources.

One issue that leads to significant practice variation is that there are often many primary care physicians, internists, a pulmonologist taking care of pneumonia patients, each physician having their own established practice patterns, which may or may not follow the agreed upon care map. Being able to understand and control the variables of care (i.e. pharmacy utilization, respiratory care, frequency and type of lab and radiology testing, admission/discharge to the ICU, etc.) is key in establishing effective standards of care.

Monitoring the top and bottom 20% of the patients in terms of costs and utilization, by physician, and then reporting those results back to the physicians and medical staff/quality committees will generally yield results in terms of minimizing variation in this complex diagnosis.

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Key success factors

Consider these important factors when analyzing pneumonia patients for cost and process improvement:

1) Managing the Pneumovax process: achieving greater compliance to increase the number of patients who receive the pneumonia vaccine can reduce the number of future pneumonia admissions or readmissions. Compliance rates will generally be higher in facilities that have more direct involvement of front line nurses in educating the patient about the vaccine and giving the actual vaccine while still an inpatient. A motivated nurse manager is seen as key to achieving higher vaccination rates as well.

2) Systematic Assessment of pneumonia patients: Implementing the "CURB65" assessment tool used by one facility when patients present in the ED proved to be a key success factor in properly identifying differing levels of pneumonia patients and determining appropriate levels of care, medications, and tests to be performed. Each patient was evaluated by the ED nurse for their CURB65 score (C=confusion, U=urea, R=respiratory , B=blood pressure, and 65=over age 65) and assigned a level, from 1-6. Each level had its own pre-determined protocol for admission status (outpatient, regular nursing floor, or ICU), and antibiotic regimen (P.O. rocefin + doxycyclene vs. IV rocefin + zythromax).

3) Standardize Preprinted Order Sets: One step to reducing variation, and therefore waste in a system, is having everyone use the same tools. Having pre-printed order sets may seem like logical step in managing care for any similar group of patients, but they order sets will not be effective unless everyone is using the same form and is trained on how they should be used. One HMC client's audit of medical records for pneumonia patients revealed significant variation in completion of the form, using different versions of the same form, and units with strong or weak compliance.

4) Managing pneumonia patients in the ICU: Naturally, the longer a pneumonia patient stays in the ICU, the greater the cost per case. Determining when a patient should be moved to a less intensive level of care can be tough to manage.

5) Involving Champions in the improvement process: Finding a physician champion to facilitate the development and implementation of and standardized protocol is always essential, and pneumonia is no exception. With so many varied types of physicians managing these patients, variation in practice patterns is inevitable, so having a champion to discuss issues with individual physicians and through the medical staff committee structure can be invaluable.

Often, it is essential to gain buy in both from the top down and the bottom up. At one HMC facility, the Corporate Adult Immunization Committee developed the pneumonia protocol, which went to the Corporate CNO for approval. She passed it on to each facility's CNO, who educated her nurse managers on the process. They, in turn educated each staff nurse. Concurrently, in-services were set up with the Medical Directors at each facility through the CNOs, who took the protocols to the Medical Executive Committees, and then on to the larger medical staffs. Internal Quality Management staff also worked to build awareness of the protocol with their respective medical staff committees.

6) An ounce of prevention...: Along with the preprinted order sets and the use of an assessment tool, it's important not to underestimate the value of reviewing the patient history form and tying in the facility's smoking cessation program (also a Core Measure) to develop a strategy of reducing the readmission rates for pneumonia patients. At one HMC facility, they saw their readmission rate decrease from 29% in 2003 to 23% in 2004 through the implementation of many of the above mention process improvement steps.