Community Acquired Pneumonia 2001

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Community Acquired Pneumonia 2001
CLINICAL QUALITY IMPROVEMENT

• Per Danielsson MD
• Chief of Adult Hospitalists, Swedish Medical
  Center
• Fred Drennan MD MHA
• Director of Performance Assessment and Improvement

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Community Acquired PneumoniaEpidemiology

• US Statistics
• 2 - 4 million cases / year --gt 10 million MD
  visits
• 6th leading cause of death 45,000 deaths per
  year
• the leading cause of infectious death
• 3.5 billion in costs in 1993
• Incidence
• General population 1-11.6 per 1000/year
• gt 65 years 25-44 per 1000/year
• gt 65 years (institutionalized) 68-114 per
  1000/year

Niederman, MS, et al (1986). Crit Care Clin.
2(3)471-95. Marrie, TJ (1994). Clin Infect Dis
18(4)501-13 Marrie TJ 9(1998). Infect Dis Clin
North Am 2(3)723-40
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Community Acquired PneumoniaEpidemiology

• Hospitalization
• GPs office 17-35
• Mortality
• Overall 1-3
• Hospitalized patients 6-24
• Requiring ICU 22-57

Niederman, MS, et al (1986). Crit Care Clin.
2(3)471-95. Marrie, TJ (1994). Clin Infect Dis
18(4)501-13
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Community Acquired PneumoniaMortality
200
180
160
140
Lack of effective therapy increase in mortality
120
Deaths per 100,000
100
80
60
40
20
0
1900
1910
1920
1930
1940
1950
1960
1970
1980
1990
Pneumonia mortality rates per 100,000 patients in
the United States from 1900-1990
Gilbert, K and Fine, MJ (1994). Semin Respir
Infect 9(3)140-52
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Community Acquired Pneumonia Bacteriology in
Hospitalized Pts
S. pneumoniae C. pneumoniae Viral Mycoplasma
pneumoniae Legionella sp. H. influenzae G-neg
enterobacteria C psittaci Coxiella burnetii Staph
aureus M. catarrhalis Other
0
5
10
15
20
25
30
Data from 26 prospective studies (5961 adults)
from 10 countries. Data from six studies
Woodhead, MA (1998)
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Streptococcus pneumoniae Resistance
Resistance to Penicillin in RTIs (19971998)
WA
2530
ME
MT
ND
OR
MN
VT
3040
NH
ID
WI
SD
gt40
MA
NY
CT
MI
WY
Percentage of non-susceptible S.
pneumoniae organisms
IA
PA
NE
NV
OH
IL
ID
UT
CO
CA
KS
MO
WV
VA
KY
AZ
NC
TN
NM
OK
Incidence of S. pneumoniae isolates resistant to
macrolides
AR
SC
VA
MS
AL
TX
LA
Azithromycin 21 Clarithromycin
23 Erythromycin 24
FL
MRL Surveillance 19971998. Data on file, Bayer
Corporation.
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Community Acquired Pneumonia Regulatory Interest

• Medicare Population HCFA/CMS
• Timing of antibiotics lt 8 hours to first dose
• Appropriateness of antibiotics
• Blood culture use
• of patients screened for and receiving
  influenza and pneumococcal vaccination

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Community Acquired Pneumonia Regulatory Interest

• JCAHO Core Measure Set
• Timing of initial antibiotic dose
• Appropriateness of antibiotics
• Pneumococcal vaccinations screening
• Smoking documentation and intervention
• In-hospital mortality and length of stay
• Readmission rates

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Community Acquired PneumoniaJCAHO/CMS Puzzle/
July 2002
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Community Acquired Pneumonia Antibiotic
Recommendations

• CDC
• Management of Community-Acquired Pneumonia in the
  Era of Pneumococcal Resistance
• Arch Intern Med 160, 2000
• IDSA
• Community-Acquired Pneumonia in Adults
  Guidelines for Management
• Clin Infect Dis 31, 2000

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Community Acquired Pneumonia Initial Therapy
and Outcomes

• 12,945 inpatient (gt 65 years of age) records
  reviewed
• Association between initial therapy and survival
• Outcome for CAP-inpatients
• Antibiotic Hazard Ratio
• 3rd-gen ceph 1
• 3rd-gen ceph macrolide .74 (.60-.92)
• Fluoroquinolone .64 (.43-.94)
• Lowest mortality with
• 2nd or 3rd generation cephalosoporin macrolide
• OR
• Quinolone

Gleason et al., Arch Int Med 1592562, 1999
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Community Acquired Pneumonia2000 IDSA Empiric
Recommendations
Inpatient- Non-ICU
Outpatient Treatment

• ?-lactam (ceftriaxone, cefotaxime) Macrolide
• Fluoroquinolone (levofloxacin, moxifloxacin,
  gatifloxacin, trovafloxacin) alone
• ?-lactam/?-lactamase inhibitor Macrolide

• Macrolide (clarithro, azithro, erythro)
• Doxycycline
• Fluoroquinolone (levofloxacin, moxifloxacin,
  gatifloxacin

Change from 1998 guidelines based upon
Gleason et al., Arch Int Med 1592562, 1999
Clin Infect Dis 31, 2000
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Community Acquired Pneumonia2000 IDSA Empiric
Recommendations
Inpatient- ICU

• ?-lactam/?-lactamase inhibitor (cefotaxime,
  ceftriaxone, ampicillin/sulbactam,
  piperacillin/tazobactam)
• and
• Macrolide or Fluoroquinolone

Clin Infect Dis 31, 2000
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Community Acquired Pneumonia SMC Antibiotic
Recommendations
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New Swedish Pre-printed orders sheet

• Front page includes
• Information for Fine Risk Scoring
• Timing for first dose of antibiotics
• Triggers for blood cultures
• Triggers for pneumococcal and influenza
  vaccination
• Triggers for Respiratory Therapy

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New Swedish Pre-printed orders sheet

• Back of order form
• Evidence-based rationale for antibiotic choices
• Description of Fine Scores and mortality risk
• Information on Respiratory Therapy protocols
• Discussion of vaccination, including
  contra-indications

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Community Acquired PneumoniaSMC Quality
Improvement Projects

• Analysis of LOS
• Timing and appropriateness of antibiotics
• Use of blood cultures
• Pneumovax rates asked/ received
• Smoking prevalence and intervention strategies
• Fine Score and admission to intensive care
  related to outcomes
• Respiratory Therapy ß-agonist use in CAP

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Community Acquired PneumoniaPatient Flow at
First Hill
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Community Acquired Pneumonia First Hill Length
of Stay DRG 89
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Community Acquired PneumoniaFH Selected Pop LOS
DRG 89
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Community Acquired PneumoniaFH Reimbursement
Source
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Community Acquired PneumoniaFH Expense
Categories
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Community Acquired PneumoniaFH Expense/
Reimbursement by LOS
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Community Acquired PneumoniaFH Expense
Breakdown for LOS6 d
Expense RB
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ALOS, Average Operating Costs, and Cases by FH
Discharge Attending Specialties
deviation from mean operating expenses
deviation from mean LOS
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Community-Acquired Pneumonia Severity Assessment
Total Points Class Mortality How to treat No
factors 1 0.1 0.4 outpatient ? 70 2 0.6
0.7 outpatient 71 - 90 3 0.9 2.8 brief
hospital observation 91 - 130 4 8.5
9.3 inpatient ? 130 5 27 31.1 inpatient, ?ICU
Risk categories according to 2 validation cohorts
(38039 inpatients and 2287 in and outpatients)
Fine MJ, et.al (1997). N Engl J Med 336243-250
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Community-Acquired Pneumonia Severity Assessment
Age gt50 yrs
Yes
Risk Class II-V (proceed to Step 2)
Co-morbid Conditions Neoplasm Liver
disease Congestive heart failure Cerebrovascular
disease Renal disease
No
Yes
No
Physical examination Altered mental
status Respiratory rate ?30 breaths-min-1 Systolic
BP lt90 mmHg Temperature lt35 C or ?40 C Pulse
?125 beats-min-1
Risk Class II-V (proceed to Step 2)
Yes
No
Outpatient Therapy
Risk Class 1
Fine et al. N.E.J.M., 1997, 336, 243
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Community-Acquired Pneumonia Severity Assessment

• Characteristic Points assigned
• Demographic factor
• Age
• Male Age (yrs)
• Female Age (yrs)
• Nursing home resident 10
• Co-morbid illness
• Neoplasm 30
• Liver disease 20
• Congestive heart failure 10
• Cerebrovascular disease 10
• Renal disease 10
• Physical Examination
• Altered mental status 20
• Respiratory rate ?30 breathsmin -1 20
• Systolic blood pressure lt90 mmHg 20
• Temperature lt95F (35C) or ?104F (40C) 15
• Pulse ? 125 beatsmin-1 10

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Community-Acquired Pneumonia Severity Assessment

• Characteristic Points assigned
• Laboratory and radiographic findings
• Arterial pH lt7. 35 30
• BUN ?30mgdL-1 (11 mM) 20
• Sodium lt130 mM 20
• Glucose gt250 mgdL-1 (14 mM) 10
• Hematocrit lt30 10
• Po2 lt8.0 kPa (60 mmHg) (room air) 10
• Pleural effusion 10
• BUN blood urea nitrogen

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Community-Acquired Pneumonia Severity Assessment
Total Points Class Mortality How to treat No
factors 1 0.1 0.4 outpatient ? 70 2 0.6
0.7 outpatient 71 - 90 3 0.9 2.8 brief
hospital observation 91 - 130 4 8.5
9.3 inpatient ? 130 5 27 31.1 inpatient, ?ICU
Risk categories according to 2 validation cohorts
(38039 inpatients and 2287 in and outpatients)
Fine MJ, et.al (1997). N Engl J Med 336243-250
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Community Acquired Pneumonia Use of
Bronchodilator Therapy

• Part of a System-to-System Collaborative between
  Swedish and Providence
• Based on information from Yakima that most
  patients admitted with CAP receive ß-agonist
  therapy despite a lack of either diagnosis or
  findings suggesting reversible airway obstruction
  RAO
• Risk of adverse effects from cardiac side effects
• Concerns validated by Swedish Respiratory Therapy
  Departments indication, use, value

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Community Acquired Pneumonia Use of
Bronchodilator Therapy

• Swedish Data 2000
• Coded diagnosis of reactive airway obstruction
  RAO at discharge
• Ballard 48.7
• First Hill 39.5
• Providence 41.2

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Community Acquired Pneumonia SMC-PHS
Collaborative
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Community Acquired Pneumonia SMC-PHS
Collaborative
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Community Acquired Pneumonia SMC-PHS
Collaborative
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Community Acquired Pneumonia SMC-PHS
Collaborative
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Community Acquired Pneumonia SMC-PHS
Collaborative
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Community Acquired Pneumonia Use of
Bronchodilator Therapy

• Next Steps
• Patient tracking
• Documentation of outcomes
• Mortality
• LOS
• Cardiac rhythm disturbances
• Cost-effectiveness analysis
• Revisions to pre-printed order sets

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Community Acquired PneumoniaNext Steps

• Finalization of the pre-printed orders for
  Community Acquired Pneumonia
• Determination and engagement of the Emergency
  Department on the critical issues
• Development a clinical pathway to support
• Nursing documentation
• Patient education materials
• Data collection methodology and reporting
• Submission of data to JCAHO July 2002

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Community Acquired Pneumonia

• Questions/ Discussion