Establishing the problem
6.1. Establishing the problem
There is little point in attempting to improve a process of care that is already highly achieved. For example, is trying to improve oxygenation assess- ment within 24 hr of admission likely to be cost-effective, when it is already performed in 94% of patients? Before embarking on QI therefore, it is essen- tial to consider the question: “What is currently happening and do we need to improve it?” Surprisingly, this is not always done. In many UK hospitals, the clinical governance agenda is largely being achieved by the local development and implementation of treatment algorithms that have not been informed by pre-implementation audit. Even if a multidisciplinary approach to develop- ment is used, which is not always the case, there is a risk that the resulting intervention may focus on areas of ongoing good practice, while neglecting important processes of care that are sub-optimally achieved. The decision about which aspects of process to measure in CAP has been discussed above and is helped by the expanding evidence-base linking process of care to out- comes; evidence-based process of care measures are shown in Table 3. In TAYCAPP, pre-implementation audit of process of care measures showed that half of all patients received appropriate antibiotics within 4 hr (the BTS rec- ommend within 2 hr) of hospital admission. Of patients with severe CAP (as defined by the BTS guidelines), 30% did not receive IV antibiotics within 24 hr. In contrast, 17% of all patients were receiving unnecessarily intensive or expensive antibiotic therapy, an important consideration given current con- cerns about antibiotic resistance and cost-efficient healthcare.
It is also important to understand how patients pass through the healthcare system (i.e., the patient journey). In TAYCAPP, identification of the pre- implementation pathway of care showed that one-third of CAP patients are admitted via the A&E department. A&E involvement in the development and implementation process was therefore deemed essential. An A&E pathway (Figure 2) and educational session were subsequently developed with the aim of increasing the proportion of CAP patients receiving antibiotics before trans- fer to the acute medical admissions unit. We were also able to identify that relatively few patients have a delayed discharge because of non-medical rea-
Pneumonia Guidelines in Practice
53 stay was more likely to be reduced for the majority of patients by focusing on
the early management of CAP, where deficits clearly existed, rather than addressing issues (e.g., rehabilitation services provision) that were unlikely to
be changed by an initiative for a single acute medical condition.
The Tayside Critical Care Pathway for the Management of Community-Acquired Pneumonia ACCIDENT & EMERGENCY PATHWAY
PATIENT with SUSPECTED/PROVEN COMMUNITY-ACQUIRED PNEUMONIA ASSESS SEVERITY of PATIENT’S PNEUMONIA
ADVICE
CORE Adverse Prognostic Features
ADVICE ONLY
ONLY
• CONFUSION (New onset, MSQ ≤ 8/10)
• RESPIRATORY RATE ≥ 30/minute Team (9–5pm) Respiratory or Medical SpR
Team (9–5pm) Respiratory
UREA >7mmol/l (if available)
• BP < 90mmHg systolic or ≤ 60mmHg diastolic or Medical SpR (5pm-9am, bleep 4691)
(5pm–9am, •
Age ≥ 50 years bleep 4691) •
PREEXISTING Adverse Prognostic Features
Significant coexisting chronic illness
ADDITIONAL Adverse Prognostic Features
Pulse oximetry < 92% on any FiO 2 (if available)
Bilateral or multi-lobar changes on CXR (if available)
TWO OR MORE PROGNOSTIC FEATURES
NO ADVERSE
ALL OTHER PATIENTS:
USE CLINICAL JUDGEMENT
CORE FEATURES
CONSIDER HOME
SEVERE PNEUMONIA THERAPY IF:
NON-SEVERE, BUT NEEDS
NO
HOSPITAL MANAGEMENT
Oral route available Satisfactory social situation Consider the Early Supportive Discharge Service (9am–5pm) OR a Community-Hospital bed
(if available/appropriate)
GIVE PRE-ADMISSION ANTIBIOTICS YES
SEVERE – CO-AMOXICLAV 1.2g IV (ALLERGY: Levofloxacin 500mg IV)
NON-SEVERE – AMOXICILLIN 1.0g PO • 1st CHOICE: AMOXICILLIN 500mg x3/day PO for 7-days
HOME THERAPY
(ALLERGY: Erythromycin OR Clarithromycin 500mg PO) • ALTERNATIVE:
ERYTHROMYCIN 500mg
OXYGEN and IV FLUIDS according to clinical need CLARITHROMYCIN 500mg x4/day PO for 7-days OR
ADMIT to ACUTE MEDICAL ADMISSIONS UNIT
x2/day PO (or MR 1g x1/day)
(BLEEP 4691)
for 7-days
(Minimum doses are stated)
PENICILLIN ALLERGY = RASH and/or ANAPHYLAXIS
• Oral fluids • Antipyretics/analgesia • Smoking advice • GIVE ALL PATIENTS A CAP
INFORMATION LEAFLET
POST DISCHARGE FOLLOW-UP
• CXR at 6-weeks for all patients at risk of lung cancer (e.g. smokers and/or age
>50 years). • Consider further investigation for those with persistent symptoms/signs • HOSPITAL to ORGANISE FOLLOW-UP ARRANGEMENTS • Influenza/pneumococcal vaccination for those at risk (see CMO guidance)
Review Date:
• Smoking advice
August 2003
54 Gavin Barlow