Respiratory Clinical Review of Patients with Community Acquired Pneumonia

Respiratory Clinical Review of Patients with Community Acquired Pneumonia DrPeter Wu Staff Specialist Department of Respiratory & Sleep Medicine Westmead Hospital Western Sydney Local Health District

How To Utilise Clinical Data to Improve Clinical Outcome? The Westmead Experience

Clinical Leadership Program 2010-2011 A program ran by Clinical Excellence Commission Part of the project requirement for completion of program An opportunity to improve clinical performance and clinical outcomes

2009-2010 HRT Data

Evidence of a Problem Respiratory infection/inflammation (E65A, E65B & E65C) makes up 30% of admissions Number 5, 4 & 2 of top 10 categories by episodes Number 4, 7 & 9 of top 10 categories by bed days Relative stay index all significant above benchmark E65A = 142.2% E65B = 117.6% E65C = 132% Most admissions made up of community acquired pneumonia

Meeting with Senior Respiratory Clinicians Problem with coding? Our patients are more complex? Our patients are more complex or present later due to lack of access to general practice and hence have more complications? Our patients are from a lower socioeconomic background? Our patients have less access to general practitioners and present sicker or utilise hospital presentations to access health care?

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Diagnostic Journey of a Systems Problem

Formation of Committee Senior clinician Respiratory advanced trainee Clinical nurse consultant Pharmacist Performance unit

High Level Flow Referral Client to Emergency comes into Department prison Triage & Diagnosis Initial Treatment & Disposition & n Community Acquired Pneumonia Discharge Home on Oral Antibiotics? Yes Community Acquired Pneumonia Initial Treatment in Emergency Department No Current status Admission to Appropriate Medical Unit According to Severity No Intravenous antibiotics Improving from Community Acquired Pneumonia? Treatment & Discharge Planning Discharge Home with Appropriate Follow Up Need further investigations or intervention Yes Discharge & Post Discharge Follow Up Discharge Planning Change to Oral Antibiotics & Mobilise

Pareto Chart Treatment & Discharge Planning 80 70 60 50 40 30 20 10 Number of Votes (%) 0 Prolonged Use of IV Antibiotics Significant Variation in Practice Lack of Weekend Ward Rounds Timing of Consultant Ward Rounds Age of Patient Incorrect Use of Physiotherapy Lack of Consultant Involvement in Decision Making Incorrect Interpretation of Severity Factors in Cause Analysis

Audit of Antibiotic Usage Matching data of patients with diagnosis of CAP with IV and oral antibiotics Exclude patients with 1) Malignancy 2) Immunocompromised patients 3) Aspiration pneumonia 4) Lung abscess 5) Empyaema 6) AECOPD

Intravenous & Oral Antibiotic Usage Total CAP patients 184 Matched iv drugs 143 35 Community Acquired Pneumonia - Westmead FY0910 (n = 184) 102 Matched tablets 165 Matched IV followed by oral AB 137 47 102 Unmatched IV followed by AB oral Matched IV followed by oral AB - IVx 1 day 102 out of 137 IV followed by AB oral - IV x 1 day

Variance in Practice Doctor Cases Average LOS Avg IV Antibiotics Duration* Avg Oral Antibiotics Duration Dr C 27 7.7 0.7 7 Dr B 48 7.2 2.8 4.4 Dr H 5 4.2 1 3.2 Dr D 16 5.6 2.7 2.9 Dr A 53 6 1.7 4.3 Dr G 10 4 1.9 2.1 Dr F 11 2.9 0.7 2.2 Dr E 14 6.6 1.6 5 Total 184 6.2 1.9 4.3 *Avg Tablet duration calculated first, then ALOS Tab duration to get IV duration

Lack of Weekend Ward Rounds Number of discharges Lack of Saturday ward round clearly affected discharges on Saturdays 10% of discharges on weekends Days of the Week

Timing of Consultant Ward Rounds Over-reliance on consultant ward rounds on Mondays & Thursdays?

Age of Patient 40 35 No of cases 30 25 20 15 10 5 0 17-26 27-36 37-46 47-56 57-66 67-76 77-86 87-96 47-56 57-66 67-76 77-86 87-96 27-36 47-56 57-66 77-86 37-46 57-66 27-36 1-10 Age 11-20 21-30 31-40 61-70 group Length of stay(days) Long length of stays are not all necessarily patients >70

Incorrect Use of Physiotherapy 149 out of 184 patients (81%) received Physiotherapy intervention The code is non-specific and does not allow us to differentiate what type of intervention was given to the patient Chest physiotherapy is not a standard recommendation for community acquired pneumonia Difficulty obtaining data from the Allied Health system

Intervention

Interventions IV Ab& Age Prolonged use of IV antibiotics, despite being of the greatest concern to the team, seem to not be a significant issue according to the data Age of patient does not seem to be a consistent influence on the LOS

Interventions Weekend Ward Rounds Increasing staffing to have a Saturday ward round, in addition to the established Sunday ward rounds Re-orientation of focus on discharges No current data with regards to outcome of intervention

Interventions -Physiotherapy Incorrect use of physiotherapy No clinical indication for chest physiotherapy for community acquired pneumonia (CAP) 81% of patients with CAP requiring physiotherapy appear to be unusually high Require more data on utilisation of physiotherapy & source of referral/indications/referring patterns Staff re-educated with regards to indications for physiotherapy in CAP and to make a direct electronic referral including indication for referral

Community Acquired Pneumonia Pathway New pathway aimed at 1) Reducing variance in practice 2) Empowering junior staff to discharge patients with consultant involvement 3) Correct use of physiotherapy 4) Minimising prolonged IV antibiotic usage 5) Incorporating assessments of severity

Community Acquired Pneumonia Pathway Pathway for Management of Community Acquired Pneumonia Does the patient have community acquired pneumonia? 1 NO Manage As Per Diagnosis YES Does the patient have immunodeficiency, structural lung problems, lung abscess or suspicion of tuberculous, Staph aureus, gram negative infection or had recent travel in tropical areas/northern Australia? NO What is the CURB-65 score? 2 YES 0-1 Manage As Per Diagnosis Consider discharge if stable co-morbid disease & no concerns re social factors, discharge from ED +/- follow in Early Discharge Clinic 3 2 Admit and commence on Ceftriaxone 1g IV daily PLUS Azithromycin 500mg po/iv daily 4 If admitted, commence on EITHER Ceftriaxone 1g IV daily OR Benzyl penicillin 1.2g IV q4h/q6h AND Roxithromycin 300mg po daily 4 Day 1 Mobilise 5 Day 2 1) Temp <38 c for 16hr AND 2) Clinically improving AND 3) Sats 90% for 30min on RA AND 4) Able to tolerate oral Rx AND 5) Stable co-morbid conditions, social needs attended & mobilising NO YES Discuss with CMO with regards to further management plans 6 INDICATION FOR ONGOING IV ANTIBIOTICS SHOULD BE REVIEWED AT 48 HOURS & DISCUSSED WITH CMO. REGISTRAR SHOULD SIGN OF ANTIBIOTIC STICKER IN MEDICAL NOTES Consider discharge home on orals on Day 1 or when indication for admission is stable +/- PACC service +/- follow up in Early Discharge Clinic 3 Inform CMO & discharge home on orals +/- PACC service +/- follow up in Early Discharge Clinic. 3 **Remember to organise CMO, GP and radiological follow up**

Community Acquired Pneumonia Sticker

Community Acquired Pneumonia Pathway Staff buy-in crucial for pathway Based on best evidence and best practice Having a projected timeline Simple sticker as alerts to being outside the pathway Flexibility in pathway & ability to opt out Reduce variance of practice Reduce over reliance on consultant ward rounds to make decisions for those who fall within the pathway Encouraging involvement & communications with CMO Regular audit of stickers in monthly Quality Improvement Meeting to ensure ongoing compliance

Community Acquired Pneumonia Pathway Setting up of facilities to accommodate more outpatient management of lower acuity cases of pneumonia Early Discharge Clinic ED Discharge Clinic

Intervention -Coding Improvement in documentation to assist in coding with Weekly problem list Monthly audits of problem lists Improvement in electronic discharge summary Drop down boxes for diagnosis and complications Weekly review of a clinical cases in meeting Weekly review of files/discharge summaries in registrar meeting 4x a year review of cases with clinical coders

Outcome

HRT July-Dec 2010

HRT July-Dec 2012

HRT July-Dec 2013

HRT July-Dec 2013

HRT July-Dec 2013

Outcome Intervention resulted in ongoing and durable change! Ongoing and durable reduction in the overall LOS and hence cost the unit/hospital, despite workload staying relatively constant?increase in emergency re admissions Increasing weekend registrar ward round did not increase weekend discharges but now spread over Saturday and Sunday Consumer satisfaction not measured No patient satisfaction survey designed Little to compare to prior to introducing change.

Conclusion Importance of using clinical data to facilitate change Importance of undertaking a diagnostic journey in solving a systems problem Need to correct clinically relevant facility specific clinical data to allow for correct solutions to be formed for a systems problem Need to engage staff on all levels to allow for systems change

Acknowledgement & Thanks Guidance team members: Prof John Wheatley Ms Jeanette Sheridan Project team members with fundamental knowledge and who worked on the project: Dr Odette Erskine, Respiratory Advanced Trainee Ms Annette Kean, Clinical Nurse Consultant Mr Yogi Mishra, Pharmacist Ms Susan Dunn, Performance Monitoring & Reporting Unit Ms Taj Askew, Performance Monitoring & Reporting Unit