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A tailored implementation strategy to reduce the duration of intravenous antibiotic treatment in community-acquired pneumonia: a controlled before-and-after study

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Abstract

We previously showed that 40 % of clinically stable patients hospitalised for community-acquired pneumonia (CAP) are not switched to oral therapy in a timely fashion because of physicians’ barriers. We aimed to decrease this proportion by implementing a novel protocol. In a multi-centre controlled before-and-after study, we evaluated the effect of an implementation strategy tailored to previously identified barriers to an early switch. In three Dutch hospitals, a protocol dictating a timely switch strategy was implemented using educational sessions, pocket reminders and active involvement of nursing staff. Primary outcomes were the proportion of patients switched timely and the duration of intravenous antibiotic therapy. Length of hospital stay (LOS), patient outcome, education effects 6 months after implementation and implementation costs were secondary outcomes. Statistical analysis was performed using mixed-effects models. Prior to implementation, 146 patients were included and, after implementation, 213 patients were included. The case mix was comparable. The implementation did not change the proportion of patients switched on time (66 %). The median duration of intravenous antibiotic administration decreased from 4 days [interquartile range (IQR) 2–5] to 3 days (IQR 2–4), a decrease of 21 % [95 % confidence interval (CI) 11 %; 30 %) in the multi-variable analysis. LOS and patient outcome were comparable before and after implementation. Forty-three percent (56/129) of physicians attended the educational sessions. After 6 months, 24 % (10/42) of the interviewed attendees remembered the protocol’s main message. Cumulative implementation costs were €5,798 (€20/reduced intravenous treatment day). An implementation strategy tailored to previously identified barriers reduced the duration of intravenous antibiotic administration in hospitalised CAP patients by 1 day, at minimal cost.

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Acknowledgments

We would like to thank G.A. de Wit (Associated Professor Medical Technology Assessment, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht) for sharing her expertise on economic evaluations with us. T.H.J. ten Cate (Professor of Medical Education, University Medical Centre Utrecht), thank you for the advice on the evaluation of education effects. Finally, we would like to thank L.C. Stijvers (Datamanager UPOD, University Medical Centre Utrecht) for his efforts in creating the database containing pharmacy data.

For this study, data from the Utrecht Patient Oriented Database (UPOD) were used. UPOD is an infrastructure of relational databases comprising data on patient characteristics, hospital discharge diagnoses, medical procedures, medication orders and laboratory tests for all patients treated at the University Medical Centre Utrecht (UMC Utrecht) since 2004. The UMC Utrecht is a 1,042-bed academic teaching hospital in the centre of the Netherlands, with about 28,000 clinical and 15,000 day-care hospitalizations and 334,000 outpatient visits annually. UPOD data acquisition and management is in accordance with current regulations concerning privacy and ethics. The structure and content of the UPOD have been described in more detail elsewhere (ten Berg MJ, Huisman A, van den Bemt PM, Schobben AF, Egberts AC, van Solinge WW. Linking laboratory and medication data: new opportunities for pharmacoepidemiological research. Clin Chem Lab Med. 2007;45(1):13–9).

Funding

This study was funded by the Netherlands Organisation for Health Research and Development (ZonMW Implementation Project, grant no. 171103003).

Conflict of interest

None to declare.

Author information

Authors and Affiliations

  1. Department of Internal Medicine and Infectious Diseases, University Medical Centre Utrecht, Utrecht, The Netherlands

    M. F. Engel, A. H. W. Bruns, R. K. Stellato, A. I. M. Hoepelman & J. J. Oosterheert

  2. Department of Internal Medicine, Meander Medical Centre, Amersfoort, The Netherlands

    A. H. W. Bruns, C. A. J. M. Gaillard & R. K. Stellato

  3. IQ Scientific Institute for Quality of Healthcare, University Medical Centre St. Radboud, Nijmegen, The Netherlands

    M. E. J. L. Hulscher

  4. Department of Internal Medicine, VU Medical Centre, Amsterdam, The Netherlands

    C. A. J. M. Gaillard

  5. Department of Internal Medicine, Diakonessen Hospital, Utrecht, The Netherlands

    S. U. C. Sankatsing

  6. Department of Pulmonary Diseases, University Medical Centre Utrecht, Utrecht, The Netherlands

    F. Teding van Berkhout

  7. Department of Geriatric Diseases, University Medical Centre Utrecht, Utrecht, The Netherlands

    M. H. Emmelot-Vonk

  8. Department of Hospital Pharmaceutics, Diakonessen Hospital, Utrecht, The Netherlands

    E. M. Kuck

  9. Department of Hospital Pharmaceutics, Meander Medical Centre, Amersfoort, The Netherlands

    M. H. M. Steeghs

  10. Department of Hospital Pharmaceutics, University Medical Centre Utrecht, Utrecht, The Netherlands

    J. H. den Breeijen

  11. Department of Biostatistics, Division Julius Centre, University Medical Centre Utrecht, Utrecht, The Netherlands

    J. H. den Breeijen

Authors
  1. M. F. Engel
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  2. A. H. W. Bruns
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  3. M. E. J. L. Hulscher
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  5. S. U. C. Sankatsing
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  6. F. Teding van Berkhout
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  7. M. H. Emmelot-Vonk
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  8. E. M. Kuck
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  9. M. H. M. Steeghs
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  10. J. H. den Breeijen
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  11. R. K. Stellato
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  12. A. I. M. Hoepelman
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  13. J. J. Oosterheert
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Corresponding author

Correspondence to J. J. Oosterheert.

Appendices

Appendix 1

Table 4 Inclusion and exclusion criteria
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Appendix 2

Table 5 Contents of the laminated pocket card used for the implementation
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Table 6 Evidence-based medicine: switching to oral medication in community-acquired pneumonia (CAP)
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Appendix 3

Table 7 Log of activities aimed at implementation
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Appendix 4

Table 8 Actual costs of executing the study intervention in participating hospitals (n = 3)
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Engel, M.F., Bruns, A.H.W., Hulscher, M.E.J.L. et al. A tailored implementation strategy to reduce the duration of intravenous antibiotic treatment in community-acquired pneumonia: a controlled before-and-after study. Eur J Clin Microbiol Infect Dis 33, 1897–1908 (2014). https://doi.org/10.1007/s10096-014-2158-z

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  • DOI: https://doi.org/10.1007/s10096-014-2158-z

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