A Multidisciplinary Pathway for Community-Acquired Pneumonia with Rapid Conversion to Oral Therapy Improves Healthcare Value

A multidisciplinary team with a goal to improve treatment for hospitalized patients with CAP was assembled that included physicians (emergency medicine, medical intensive care unit, infectious disease/antimicrobial stewardship, hospitalists), pharmacy, value engineering, information technology and the quality department. A standardized CAP orderset for patients presenting to the ED was developed. When an ED patient receives a chest radiograph and an antibiotic order, a best practice alert (BPA) is triggered stating, "If this antibiotic is for pneumonia, click ‘Open orderset'." If selected, this orderset provides guidance to providers to appropriately triage patients (ICU admission, Floor admission or Home Discharge), assess the risk for drug resistance, order appropriate diagnostic testing, and select ‘best practice' antibiotics. Patients admitted to the hospital floor are given a single intravenous (IV) antibiotic dose, then are switched to oral antibiotics after 24 hours for a total duration of 5 days. Atypical coverage with azithromycin is discontinued after 24 hours unless Legionella urine antigen returns positive. Pre-implementation training was provided to providers, nurses, respiratory therapists and pharmacists involved in patient care. A stewardship team including an infectious disease physician and pharmacist would review charts of patients on hospitalists teams and provide feedback for consistent antibiotic administration.

Title: A Multidisciplinary Pathway for Community-Acquired Pneumonia with Rapid Conversion to Oral Therapy Improves Healthcare Value Authors: Claire Ciarkowski, MD1, Tristan T. Timbrook, PharmD, MBA2, Karli Edholm, MD1, Nathan D. Hatton, MD4, Christy L. Hopkins, MD4, Frank Thomas, MD, MBA1, Matthew N. Sanford, MBA5, Elena Igumnova6, Russell J. Benefield, PharmD2, Polina Kukhareva, MPH, PhD7, Ken Kawamoto, MD, MHS, PhD7, Emily Spivak MD, MHS8 Affiliations: 1. Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA 2. Department of Pharmacy, University of Utah Health, Salt Lake City, Utah, USA 3. Division of Pulmonary Medicine, Department of Medicine, University of Utah, Salt Lake City, UT, USA 4. Division of Emergency Medicine, Department of Surgery, University of Utah School of Medicine, 5. 6. 7. 8. Salt Lake City, Utah, USA Value Engineering, University of Utah Health, Salt Lake City, Utah, USA Decision Support, University of Utah Health, Salt Lake City, Utah, USA Department of Biomedical Informatics, University of Utah Health, Salt Lake City, Utah, USA Division of Infectious Diseases, Department of Internal Medicine, Salt Lake City, Utah, USA Statement of Problem or Question: How does the Initiation of a Clinical Care Pathway for Community Acquired Pneumonia (CAP) Effect Antibiotic administration and Hospital Costs? Description A multidisciplinary team with a goal to improve treatment for hospitalized patients with CAP was assembled that included physicians (emergency medicine, medical intensive care unit, infectious disease/antimicrobial stewardship, hospitalists), pharmacy, value engineering, information technology and the quality department. A standardized CAP orderset for patients presenting to the ED was developed. When an ED patient receives a chest radiograph and an antibiotic order, a best practice alert (BPA) is triggered stating, "If this antibiotic is for pneumonia, click ‘Open orderset'." If selected, this orderset provides guidance to providers to appropriately triage patients (ICU admission, Floor admission or Home Discharge), assess the risk for drug resistance, order appropriate diagnostic testing, and select ‘best practice' antibiotics. Patients admitted to the hospital floor are given a single intravenous (IV) antibiotic dose, then are switched to oral antibiotics after 24 hours for a total duration of 5 days. Atypical coverage with azithromycin is discontinued after 24 hours unless Legionella urine antigen returns positive. Pre-implementation training was provided to providers, nurses, respiratory therapists and pharmacists involved in patient care. A stewardship team including an infectious disease physician and pharmacist would review charts of patients on hospitalists teams and provide feedback for consistent antibiotic administration. Measures of success The primary endpoints of this quality improvement project are median hospital length of stay (LOS), IV antibiotic administration duration, and relative mean cost. Findings to Date The pathway was implemented on 9/1/2017. The pre-intervention period was defined as 9/1/2016 thru 8/31/2017 and included 411 patients. A one month wash out period from 9/1-9/30/2017 was included for education of the BPA and initiation of stewardship team. The post implementation period was defined from 10/1/2017 until 8/31/2018 and included 368 patients. There was no difference in demographics between pre-intervention and post intervention groups including age, gender and case mix index. Our intervention produced significant reductions in median hospital LOS (3.69 to 3.08 days, p 0.014), median IV antibiotic duration (interquartile range 3 days to 2 days, p<0.001) and relative mean cost (1.00 to 0.65, p0.02). There were no significant changes in 30 day readmissions or mortality. Key Lessons for Dissemination The early initiation of an EHR driven CAP care pathway in the ED supplemented by a dedicated antimicrobial stewardship team improves healthcare value by enhancing the quality of care through decreased IV-antibiotic duration, shorter hospital LOS and lowered costs.