A comprehensive approach to achieving near 100% compliance with The Joint Commission Core Measures for pneumonia antibiotic timing

Abstract

Background

Adherence to The Joint Commission (TJC) Core Measures benchmarks is required for hospital accreditation, and data are publicly reported as an indication of hospital quality. Published approaches to date for adhering to the pneumonia antibiotic timing (PN5c) Core Measure have shown moderate to limited success in reaching high levels of compliance.

Objective

The objective of the study was to evaluate the effectiveness of a 3-phased intervention directed at improving compliance with TJC pneumonia antibiotic administration within the 6-hour requirement (PN5c) in an academic urban emergency department.

Methods

A 3-phase interventional study with retrospective analysis of contemporaneous data collection during a 57-month period ending September 2009 was performed. Phase 0 was baseline, phase 1 was physician evaluation at triage, phase 2 was implementation of a specific pneumonia screening tool and pathway, and phase 3 was implementation of an emergency department electronic medical record system that facilitates removing subjects with “diagnostic uncertainty” from consideration. Main outcome measure was the proportion of patients receiving antibiotics within 6 hours among those meeting PN5c criteria. Mean times to antibiotics and percentage of compliance with PN5c were compared for each phase.

Results

Percentage of compliance with PN5c increased from a baseline of 77% through each of the 3 phases: 85%, 91%, and 95%, respectively (Cochran-Armitage trend, P < .001). Mean time to antibiotic administration decreased from a baseline of 285 minutes with each successive intervention to 224, 189, and 169 minutes, respectively (linear regression, P < .001).

Conclusion

Implementation of a structured intervention that includes early physician triage, a screening tool for immediate imaging and reporting, and electronic record–facilitated compliance review effectively improves TJC PN5c compliance to high levels.

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%.