Pneumonia Order Set Development

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Pneumonia Order Set Development

• Magic Valley Regional Medical Center
• Al Frost MS MD
• Salli Valder RN

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Disclaimers

• I am an ophthalmologist no clinical expertise in
  pneumonia!
• Only working with our physicians for the last
  year on PI pneumonia orders one of our first
  projects
• Second revision of our pneumonia orders due to
  come out next two weeks

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CAP at MVRMC (June 2004)

• For FYTD (9 months)246 cases
• 4/5 come through ED193/246 cases
• 40 of care provided by family practice docs the
  rest by internists

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Why are order sets useful?

• Present options for care based on EBM
• Reduce omissions and phone calls
• Standard format and legibility aids nursing
• Increase efficiency of care
• Improve documentation of physician thinking.
• Improve outcomes!
• Systems improvement
• Promotes physician/staff collaboration

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Challenges from Physicians

• Resistance to change
• Cookbook medicine less involved in care
• Logical thought process tied to writing orders by
  hand
• Order sets not on the chart when should be
• Resentment of CMS and JCAHO
• However Growing acceptance of PI concepts and
  need for systems change

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Main goals

• CMS indicators would be a prominent part
• Framework of indicators with commonly accepted
  pneumonia treatment modalities
• Order set should also function as a documentation
  tool for physicians and chart reviewers
• Address the needs of ED docs immunization

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Process of development

• Early worked with interested internist, FP and
  ED doc to build elements of set
• Worked with Kurt Stevenson on antibioticsexisting
  guidelines
• Surveyed order sets from other hospitals
• Created workgroup of about 10 people including
  docs, nursing, quality, ED and critical care to
  meet and discuss orders worked out nearly
  complete product

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Process (contd)

• Passed order set around to respiratory therapy,
  pharmacy, dietary, and others to include
  protocols, check accuracy, etc.
• Placed version in all physicians boxes (those who
  care for pneumonia patients) for input.
• Then took to clinical departments for approval
  Medicine, FP, and ED. This delayed the process
  but important.

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Process (contd)

• Forms committee approves for final printing.
  Checks abbreviations, dosages, and formatting one
  last time.
• Printing now using commercial printer
• Distribution Hospital units and offices.
  Personally take them with cover letter.

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Details on revised order set

• CMS/JCAHO indicators are shaded for emphasis
• Immunization piece changed to remove the direct
  responsibility from ED docs
• Smoking cessation piece changed to remove option
  for ED
• Documentation of first dose of antibiotic given
  in ED

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What do we measure?

• Indicators
• Actual use of order set 84 when last measured
  1st quarter 2004 (100 for FPs)
• Give physicians data as a department and as
  individuals

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Problems

• Pneumococcal immunization
• Not addressed in ED
• Not always addressed in HP
• Not always addressed by initial nurse assessment
• Patients cannot remember status
• Resistance by physicians to nurse initiated
  process
• Difficulty transfer of admission to discharge
  order
• Solution in revision
• Case management pilot

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Problems

• Timely 1st antibiotic therapy lt4 hours
• Works best when antibiotic given in ED
• ED does not always document on admission set
• Time required for stabilization and work-up in ED
  delays antibiotic-rare

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Problems

• Smoking cessation
• 55 compliance with eligible patients
• Solution no longer an option on order set
• Will be a focus of great emphasis by nursing

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CAP Results 1st quarter 2004

• Oxygenation assessment 100
• Pneumococcal screening/vaccination 53
• Blood cultures 93
• Smoking 55
• Antibiotic timing 88 lt4 hrs
• Mean 202 minutes