Characterizing and Developing Strategies for the Treatment of Community – acquired Pneumonia at a Community Hospital

Context

Patients admitted to Lions Gate Hospital with a primary diagnosis of community-acquired pneumonia (CAP) have a mean length of stay (LOS) of 9.1 days compared to 7.9 days for peer group hospitals. This difference of 1.2 days results in an annual potential bed day savings of 397 and warranted an investigation into the management of CAP.

Objectives

To characterize and provide recommendations for the management of CAP at our institution.

Setting

A Canadian community hospital consisting of 260 acute and 325 extended care beds.

Design

A retrospective chart review was conducted for patients admitted with a primary diagnosis of CAP between May 1, 2000 and August 31, 2000.

Main Outcome Measures

Data collected included:

1) the decision to hospitalize based on the calculated PSI score,

2) whether guideline-recommended diagnostic tests (chest X-ray, sputum and blood cultures) were performed,

3) antibiotic selection for pneumonia in terms of choice, route and cost,

4) timing and appropriateness of step-down (SD) from IV to PO antibiotics,

5) whether early discharge occurred and

6) length of stay.

Results

Fifty-one patients were included in the study with an average age of 75 ± 15 years. These patients had a mean LOS of 9.9 days, and a median LOS of 5 days. Based on Pneumonia Severity Index (PSI) scores calculated for each patient, eight patients could have potentially been treated on an outpatient basis with a low risk of mortality from CAP. Initial empiric antibiotic choices were consistent with the Canadian CAP guidelines in 53% of patients, with inconsistencies arising mainly due to cephalosporin monotherapy and azithromycin monotherapy regimens being prescribed. Step-down (SD) from IV to PO antibiotics occurred in approximately 39% of patients. An additional 24% of patients could have been stepped-down, and SD was not applicable in 37% of patients. The potential annual cost avoidance from implementing admission criteria based on a PSI score, applying SD criteria and promoting early discharge criteria was estimated to be $206,300.

Conclusions

Considerable variability exists in the treatment and management of CAP. A CAP pre-printed order sheet was developed in order to address the issues identified in this study and provide consistency in the management of CAP at our institution.

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