A quality improvement initiative to improve adherence to national guidelines for empiric management of community-acquired pneumonia in emergency departments

Objective. The objective of this study was to improve the concordance of community-acquired pneumonia management in Australian emergency departments with national guidelines through a quality improvement initiative promoting concordant antibiotic use and use of a pneumonia severity assessment tool, the pneumonia severity index (PSI). Design and Interventions. Drug use evaluation, a quality improvement methodology involving data collection, evaluation, feedback and education, was undertaken. Educational interventions included academic detailing, group feedback presentations and prescribing prompts. Setting and Participants. Data were collected on 20 consecutive adult community-acquired pneumonia emergency department presentations by each hospital for each of three audits. Main Outcome Measures. Two process indicators measured the impact of the interventions: documented PSI use and concordance of antibiotic prescribing with guidelines. Comparisons were performed using a Chi-squared test. Results. Thirty-seven hospitals, including public, private, rural and metropolitan institutions, participated. Twenty-six hospitals completed the full study (range: 462–518 patients), incorporating two intervention phases and subsequent follow-up audits. The baseline audit of community-acquired pneumonia management demonstrated that practice was varied and mostly discordant with guidelines. Documented PSI use subsequently improved from 30/518 (6%, 95% confidence interval [CI] 4–8) at baseline to 125/503 (25%, 95% CI 21–29; P, 0.0001) and 102/462 (22%, 95% CI 18–26; P, 0.0001) in audits two and three, respectively, while concordant antibiotic prescribing improved from 101/518 (20%, 95% CI 16–23) to 132/462 (30%, 95% CI 26–34; P, 0.0001) and 132/462 (29%, 95% CI 24–33; P, 0.001), respectively. Conclusions. Improved uptake of guideline recommendations for community-acquired pneumonia management in emergency departments was documented following a multi-faceted education intervention.