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IHS Best of the Best Series: Community Acquired Pneumonia

Gwinnett Medical Center

Measure Feb ‘06

Oxygenation Assessment 100%

Blood Culture Prior to Antibiotic 90%
Antibiotic Timing 90%
Antibiotic Selection 100%
Smoking Cessation 100%
Pneumococcal Vaccine 100%
Influenza Vaccine 100%

Antibiotics within 4 hours

• Developed triage criteria for ordering of chest x-ray to expedite pneumonia diagnosis.
• Triage criteria did not increase the number of chest x-rays being ordered.
• Decrease in average time arrival to chest x-ray:
– EMS/Ambulance Patients (n=49): 101 minutes
– Private Vehicle Patients (n=69): 156 minutes
– Test Patients - EMS/Private Vehicle (n=32): 53 minutes
Lessons Learned
• Importance of physician involvement.
• Need to meet frequently with key team members – Reliability Huddle.
• Involvement of other disciplines: pharmacy, case management.
• Staff involvement and support for tests of change.

Baylor University Medical Center

AIM: By March 31, 2006 the Baylor University Medical Center Emergency Department will provide antibiotic
therapy within 4 hours of triage to 90% of the patients who have a diagnosis of pneumonia at the time of
presentation by improving access and use of the pneumonia protocol.

Segmentation: Patient Population

Approximately 90% of pneumonia come through the Emergency Department. Clearly identifying responsibilities
and ownership of the nursing and medical staff was one of the greatest areas for improvement. The focus of this
improvement project is all clearly diagnosed adult pneumonia patients is the segment of this initiative.
Patient Identification : productive cough with or without fever, shortness of breath and oxygen saturation of <
Assessment of ED process
• Communication was the true failure not the registering the patient
• Triage nurse was processing the patient correctly but communication between radiologist and
ED staff varied between individuals. Lead to standardizing roles and responsibilities.
• Protocol was developed but not readily available to staff – didn’t know where it was kept.
• Consistent in knowledge of protocol but practiced varied between triage nurse and the charge
• Resources of space to treat patient (ED rooms full)
ED Pneumonia Improvement Project

Multiple Cycles to Implement Protocol Use

Use of PNE protocol
ning A P Cycle 6: Updated protocol – nursing
ar education (3/24/06) –
S D Standardization/Prevention
P A Cycle 5: Redefined steps in process by role 
S P (3/20/06) – Failure Detection
A P Cycle 4: Engaged triage and charge nurses re: roles and
responsibilities (#/9/06) – Standardization/Prevention
Cycle 3: Flow of process - new protocol presented to
ED leadership (2/21/06)
Will protocol be
Cycle 2: Redesigned CXR reporting flow (2/16/06) –
useful for PNE
patients in ED? Failure detection

Cycle 1: Assessment of ED processes by team (1/19/06)


© 2005 Baylor Health Care System

1st Phase Pneumonia Protocol: CXR STAT

Responsible Person: Triage RN or Primary RN
Notify Access Service clerk – generate chart immediately
Place an armband on the patient
Have the patient put on gown
Order 2-view CXR in BCON. In comment field type CAP protocol
and the room the patient is in. example: triage bay 3 or 11A
If the patient cannot be taken directly to a treatment room, the triage nurse is responsible for initiating
the protocol.
If the patient is taken directly to a treatment room, the primary nurse is responsible for initiating the
2nd Phase: CXR Result or Radiology
Responsibility: Radiologist and/or Radiology Resident
Radiologist to immediately call the result to CC at 2-0317.
Radiologist will document the time of the verbal report.
3rd Phase: Notification
Responsibility: Charge Nurse
Locate patient and notify MD of pneumonia findings on CXR.
Notifies assigned ED nurse of CXR result.
4th Phase: Initiation of Treatment
Responsibility: ED Physician
MD orders blood cultures (if desired) and antibiotics.
5th Phase: Completion of Treatment
Responsibility: RN
Two sets of blood cultures (MD discretion), drawn from TWO DIFFERENT SITES, one right after the
If blood cultures ordered, RN obtains cultures and documents, in designated area on ED order sheet,
time both
cultures were drawn.
Antibiotic started.
IHS Best of the Best Series: Community Acquired Pneumonia continued
St. John’s Hospital Springfield, Missouri
First Segment Description Composite Measure 95%, All or nothing 90%
ED patients who:
– arrived by private vehicle
– presented to triage
– were admitted with a working diagnosis of pneumonia
Identified Failure Processes
• Identification of CAP patient at triage
• Antibiotic not administered within 4 hours of arrival
• Blood cultures not obtained before first antibiotic
Changes Tested
• Triage criteria development for CAP patients
– Three symptom criteria: cough, fever, dyspnea
– Added altered LOC, age parameters
– Vital signs improved specificity
• CAP protocol initiated at triage
• Pneumonia careset implemented
– CBC, BMP, two blood cultures, PA/lateral CXR
• Blood cultures before antibiotic
– Label to document time blood cultures obtained
– Omnicell prompt to draw BC before antibiotic administration
• Improved documentation of antibiotic administration
• Checklist developed to facilitate transfer of care
– Checklist too detailed, revisions made
• Colored Band-Aids


Two or more of the

following :
Fever , cough , SOB,
altered LOC , > 50 yrs

Pulse ox < 94%

Any Pulse ox < 90%
Temp > 104 F
Temp > 100 F
HR > 100 abnormal HR > 125
RR > 30
RR > 20
vital signs SBP < 90

Order CBC, BMP,
PA/lateral CXR Blood Cultures X 2
PA/ lateral CXR

Discuss with physician to

administer antibiotics < 4 hours

St. John’s Hospital

St Johns’ Lessons Learned

• Physician champion / hospitalist involvement
• Weekly team meetings
– review PDSA
– failure analyses
• Front line staff engagement
• Acute Care Center
• Incorporate IHI initiatives in other meetings