Rural Hospital
INTRODUCTION
Community-acquired pneumonia (CAP) is the sixth leading cause of death in the U.S. It affects approximately 5.6 million patients in the U.S. annually, and nearly two million patients require hospitalization for it. The financial impact of CAP is significant, and the cost of treatment is estimated to be nearly $10 billion; the primary cost-driver is the length of stay (LOS) in a hospital.
Numerous studies have identified specific factors that are associated with improved patient outcomes, including time to antibiotic administration, blood culture collection, and appropriate empirical antibiotic selection. The evidence also suggests that some of these factors may improve institutional outcomes, such as a decreased LOS and the cost per patient.
The Infectious Disease Society of America (IDSA) and the American Thoracic Society (ATS) have published treatment guidelines for CAP to improve patient care. Although the evidence does indicate that both improved patient care and improved institutional outcomes are associated with implementing practice guidelines, much variation still exists. Because of these variations and the high prevalence of CAP, the Centers for Medicare and Medicaid Services (CMS) has included CAP as a quality-improvement initiative.
Given the high prevalence of CAP and the wide variations in treatment within its own institution, Lakes Region General Hospital (LRGH) has developed and implemented CAP treatment guidelines. These guidelines focus on (1) the appropriate choice of initial antibiotic therapy and (2) administration of therapy within two hours of an order.
Laboratory and procedure orders were suggested on the basis of a modified Fine score classification contained within the Pneumonia Patient Outcomes Research Team (PORT) study. A care-management approach was instituted. The pharmacy staff evaluated all patients who were admitted with a primary diagnosis of CAP. An algorithm was developed to facilitate a transition from intravenous to oral (IV to PO) antibiotics in selected patients. A nurse care manager assessed patients’ need for home oxygen and respiratory care services to facilitate discharge planning. It was expected that adherence to these CAP guidelines would improve the quality of care and reduce the financial burden resulting from CAP! The objectives of this study included assessing the improvements in quality of care, the LOS, and the mean charges of treating patients before and after implementation of the guidelines.
SETTING
Lakes Region General Hospital (LRGH) is a 137-bed rural acute-care facility in Laconia, New Hampshire, a town of 15,000 people. The hospital serves as a designated rural referral center for a widely dispersed population of approximately 75,000 people in the central and northern regions of the state. It has a full complement of physicians, including pulmonary critical-care services. In this setting, CAP was the second most common diagnosis on admission in 1999, the year this program started. The impact of CAP on the utilization of hospital and community resources is substantial, and this initiative was expected to have a positive impact on the hospital and the target population.
