How does the Initiation of a Clinical Care Pathway (CCP) for Community Acquired Pneumonia (CAP) Effect Antibiotic Administration and Hospital Costs?

From the 2018 HVPAA National Conference

Claire Ciarkowski (University of Utah School of Medicine), Emily Spivak (University of Utah School of Medicine), Frank Thomas (University of Utah), Karli Edholm (University of Utah School of Medicine), Christy Hopkins (University of Utah), Matt Sanford (University of Utah), Elena Igumnova (University of Utah), Tristan Timbrook (University of Utah), Jacob Pettit (University of Utah), Nathan Hatton (University of Utah School of Medicine)

Background

CAP is a leading cause of hospitalization and death worldwide. The utilization of clinical practice guidelines has been associated with improved clinical outcomes and adherence to best practices for treatment of CAP. A review of the electronic health record (EHR) at our institution identified seven different pneumonia ordersets.

Objectives

The object of this value project was to (1) develop and execute a standardized EHR “best practice” pathway for the treatment of CAP and (2) determine how the use of this CCP impacts laboratory utilization, intravenous antibiotic administration, hospital length of stay (LOS), and costs for patients admitted to a medical floor.

Methods

(1) A multidisciplinary team was assembled that included physicians (emergency medicine, medical intensive care unit, infectious disease/antimicrobial stewardship, hospitalists), pharmacy, value engineering, information technology and the quality department. (2) A standardized CAP orderset for patients presenting to the ED was developed.  (3) Pre-implementation training was provided to providers, nurses, respiratory therapists and pharmacists involved in patient care.

An overview of CAP CCP is as follows: When an ED patient receives a chest radiograph and an antibiotic order, a best practice alert (BPA) is triggered stating, “If this antibiotic is for pneumonia, click ‘Open orderset’.” If selected, this orderset provides guidance to providers to appropriately triage patients (ICU admission, Floor admission or Home Discharge), assess the risk for drug resistance, order appropriate diagnostic testing (blood/sputum cultures, urinary antigen testing), and select ‘best practice’ antibiotics. Patients admitted to the hospital floor

with a DRIP (Drug resistance in pneumonia) score <4 are given a single intravenous antibiotic dose, then are switched to oral antibiotics after 24 hours for a total duration of 5 days. Atypical coverage with azithromycin is discontinued after 24 hours unless Legionella urine antigen (Uag) returns positive.

Demographics were compared by t-tests, chi square tests and Fisher’s exact test. Differences in intravenous antibiotics duration and hospital LOS were compared via negative binomial regression while differences in mean costs were compared via a generalized linear model with a log link and gamma family.

Results

All patients (n=113) consecutively admitted through the ED from September 1, 2017-January 31, 2018 with an ICD diagnosis of CAP were evaluated. Two groups compared: (1) Patients in which the CAP ‘Orderset NOT Started in ED’ (n=53) vs. (2) Patients in which the CAP ‘Orderset Started in ED’ (n=60).  We observed a significant increase in the use of appropriate labs (p<0.001) as well as a decrease in duration of intravenous antibiotics (p=0.047) in the CCP group compared to the patients not started on the pathway.  See Table 1.

Conclusion

The initiation of an EHR driven CAP CCP significantly (p< 0.05) improves appropriate micro-laboratory utilization and reduces IV-antibiotic duration. While not statistically significant, patients who had the orderset utilized had an average 20% (95% CI: -1%, 37%) decrease in the length of stay as compared to those who did not have it (p=0.07). Similarly, use of the order set was also associated with a trend toward decreased cost (estimated 21% decrease (95% CI: -2%, 40%, p=0.07).

Implications for the Patient

CAP remains a common and costly medical condition. The early initiation of an EHR driven CAP care pathway in the ED improves healthcare value by enhancing the quality of care through improved micro-laboratory utilization, improved antibiotic usage and decreased IV-antibiotic duration, and possible shorter hospital LOS and lowered costs.

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