Clinical study
A statewide initiative to improve the care of hospitalized pneumonia patients: the Connecticut Pneumonia Pathway Project

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Abstract

Purpose

A statewide quality improvement initiative was conducted in Connecticut to improve process-of-care performance and to decrease length of stay for patients hospitalized with community-acquired pneumonia.

Setting and methods

Data were collected on 1,242 elderly (≥65 years) pneumonia patients hospitalized at 31 of 32 acute care hospitals between January 16, 1995, and March 15, 1996, and on 1,146 patients hospitalized between January 1, 1997, and June 30, 1997. Interventions included feedback of performance data (Qualidigm, the Connecticut Peer Review Organization), dissemination of an evidence-based pneumonia critical pathway (Connecticut Thoracic Society), and sharing of pathway implementation experiences (hospitals). Process and outcome measures included early antibiotic administration, blood culture collection, oxygenation assessment, length of stay, 30-day mortality, and 30-day readmission rates. Analyses were adjusted for severity of illness and hospital-specific practice patterns.

Results

After the statewide initiative, improvements were noted in antibiotic administration within 8 hours of hospital arrival (improvement from 83.4% to 88.8%, relative risk [RR] = 1.21; 95% confidence interval [CI]: 1.10 to 1.32), oxygenation assessment within 24 hours of hospital arrival (93.6% to 95.4%; RR = 1.23, 95% CI: 1.11 to 1.38), and length of stay (7 days to 5 days, P <0.001). There were no significant changes in blood culture collection within 24 hours of hospital arrival, blood culture collection before antibiotic administration, 30-day mortality, or 30-day readmission rates.

Conclusions

Statewide improvements were demonstrated in the care of hospitalized pneumonia patients concurrent with a multifaceted quality improvement intervention. Further research is needed to separate the effects of the quality improvement interventions from secular trends.

Section snippets

Collaboration

This collaboration took place in Connecticut from 1996 to 1997, when the Connecticut Thoracic Society and Qualidigm (the Connecticut Peer Review Organization) decided to conduct a statewide initiative to improve the care of hospitalized pneumonia patients by increasing the performance of evidence-based processes of care. Because many Connecticut hospitals were developing critical pathways to standardize process-of-care performance and to decrease length of stay, the Thoracic Society decided to

Results

There were 2,200 (20.3%) patients with a discharge diagnosis of pneumonia selected for abstraction from 10,843 total cases during the baseline period, and 2,014 (34.9%) patients selected from 5,768 total cases during the follow-up period. The range of sampling fractions per hospital was 8.1% to 56.9% during the baseline period and 13.3% to 100.0% during the follow-up period. Case confirmation (83.9% vs. 83.9%, P = 1.0) and exclusion rates (34.9% vs. 34.8%, P = 0.95) were similar in both

Discussion

In this statewide quality improvement initiative, we observed that a multifaceted improvement intervention was accompanied by increases in process-of-care performance. Consistent with our study’s focus on processes of care, we observed an increase in receipt of antibiotics within 8 hours of hospital arrival and a decrease in median time to initial antibiotics. Performance of oxygenation assessments within 24 hours of hospital arrival and blood culture collection before antibiotic administration

Acknowledgements

The authors would like to acknowledge Kelly Forsyth and Amy Morrissey for their administrative support in preparing the manuscript.

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    Dr. Fine was supported in part by a grant from the Polly Annenberg Levee Charitable Trust, Washington, DC. The analyses upon which this publication is based were performed under Contract Number 500-96-P549, entitled “Utilization and Quality Control Peer Review Organization for the State of Connecticut,” sponsored by the Centers for Medicine and Medicinal Services (CMS), Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the U.S. Department of Health and Human Services nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. government. The authors assume full responsibility for the accuracy and completeness of the ideas represented. This article is a direct result of the Health Care Quality Improvement Program initiated by the CMS, which has encouraged identification of quality improvement projects derived from analysis of patterns of care, and therefore required no special funding on the part of the contractor. Ideas and contributions are welcomed by the authors concerning experience with the issues presented.

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