Original ContributionA comprehensive approach to achieving near 100% compliance with The Joint Commission Core Measures for pneumonia antibiotic timing☆,☆☆
Introduction
Improving patient care and creating benchmarks as standards of quality are increasingly becoming a focus of modern health care. There is a desire to improve accountability and quality by setting national standards and requiring hospitals to publicly report their performance. Furthermore, hospital payments will soon be tied to level of compliance with certain measures, so-called pay for performance [1], [2]. Many of these measures relate to patient care in the nation's emergency departments (EDs).
The Center for Medicare and Medicaid Services (CMS) and The Joint Commission for the Accreditation of Hospitals (TJC) have required hospitals to report on 8 measures of quality since 2005 [3]. It is expected that this list will grow substantially over the next several years [1]. The delivery of antibiotics to admitted patients with pneumonia within 6 hours (PN5c) is one such Core Measure [3].
There were almost 1.3 million patients hospitalized with a primary diagnosis of pneumonia in 2003, with a mortality rate of 5.1% and total care cost of nearly $10 billion. The CMS and TJC point to several studies that demonstrated a relationship between antibiotic timing and survival and decreased hospital stay among patients admitted to the hospital with pneumonia [4], [5], [6], [7], [8], [9]. These studies have been criticized for several methodological problems, such as restricted patient populations, potential unmeasured cofounders, and evaluating related but not equivalent end points [9], [10], [11], [12], [13], [14], [15], [16], [17], [18]. Although the controversy regarding the validity of these measures continues, there is no indication from CMS or TJC that there will be any significant changes forthcoming. As such, hospitals are under enormous pressure to improve their performance [2], [19], [20].
Research has been done to define the barriers to meeting the antibiotic timing requirements [20], [21], [22], [23], [24], [25], [26], [27], [28], and operational interventions attempted to create improved systems that increase performance with this measure [28], [29], [30], [31], [32], [33], [34], [35]. Results however show only moderate improvement (between 56% and 86% compliance) [28], [29], [30], [31], [32], [33], [34], [35], with no intervention thus far approaching 100% compliance. We sought to determine the effectiveness of a 3-phased operational intervention that included (a) creating a work flow designed to improve overall ED efficiency [36], (b) introduction of a comprehensive PN5c pneumonia protocol, and (c) deployment of a comprehensive electronic ED information system (EDIS) that facilitated work flow and PN5c Core Measures documentation. The goal was to achieve near 100% compliance with the PN5c Core Measure compared with a baseline compliance of 76%.
Section snippets
Study design
A 3-phase comparative intervention study with contemporaneous data collection was conducted over a 57-month period from January 2005 through September 2009, with the 3 phases representing incremental interventions. Phase 1, a comprehensive physician at triage program, was implemented in February 2006; phase 2, triage-initiated pneumonia pathway, was implemented in January 2007; and phase 3, electronic documentation assistance, was implemented in July 2008. Baseline data were derived from
Results
There were 318 patients who met PN5c criteria during the baseline period, 287 in phase 1, 397 in phase 2, and 192 patients in phase 3 (Table 1).The preintervention average 6-hour compliance rate was 76.4%, which increased to 85.4% during phase 1 (ie, 9.0% absolute gain; 95% confidence interval [CI], 2.8%-15.2%), to 91.2% in phase 2 (5.8% absolute change; 95% CI, 0.9%-10.8%), and finally to 95.3% after the third intervention (4.1% absolute change; 95% CI, 0.0%-8.2%) (Cochran-Armitage trend, P <
Limitations
The study was conducted at a single site and may not be generalizable to other EDs, particularly those that do not host teaching programs or are not situated within major urban teaching centers. In addition, given the resource intensiveness of some of the interventions, the system may not be transferable to all institutions. Furthermore, operational costs may not be the same in every institution. During phase 1, although our operational program included the expectation that a team member saw
Discussion
There is significant controversy surrounding the medical importance of PN5c quality indicator and the evidence used to support it [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [40]. The original Core Measure was derived from retrospective data on intensive care unit and elderly patients [4], [5], [6], [7], [8], and the regulations were promulgated by medical societies without emergency representation and whose members have little to no experience with presentations or patient
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Improving emergency physician performance using audit and feedback: A systematic review
2015, American Journal of Emergency MedicineCitation Excerpt :Only 2 of the 24 studies used the organizational intervention [26,28]. Twelve of the 24 studies used a combination of the different types of interventions [16,20,21,23-25,29-31,33,35,36]. The medium of the intervention was identified in each the 24 studies which were categorized as: (1) written, (2) verbal, (3) electronic, and (4) a combination of media.
Using Dedicated Nurses to Improve Core Measures Compliance
2014, Nursing Clinics of North AmericaApproaches to promoting the appropriate use of antibiotics through hospital electronic prescribing systems: a scoping review
2017, International Journal of Pharmacy Practice
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No external funding supported this study; no conflicts of interest.
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Presented in part at the annual meeting of the Society of Academic Emergency Medicine, New Orleans, LA, May 13-17, 2009.