The impact of standardized order sets and intensive clinical case management on outcomes in community-acquired pneumonia

Steven Fishbane, Michael S. Niederman, Colleen Daly, Adam Magin, Masateru Kawabata, André De Corla-Souza, Irum Choudhery, Gerald Brody, Maureen Gaffney, Simcha Pollack, Suzanne Parker

Research output: Contribution to journalArticle

37 Citations (Scopus)

Abstract

Background: Community-acquired pneumonia is a frequent cause for hospital admission that results in significant costs to the health care system. The length of hospital stay (LOS) affects costs as well as risk for nosocomial medical complications. The purpose of this study was to test whether the addition of intensive clinical case management to clinical guidelines could lead to a reduction in LOS that was not achievable by guidelines alone, while maintaining quality of care. Methods: Patients were studied in 3 sequential blocks at a single hospital from November 2002 to February 2005. Block 1 patients (n=110) were given conventional treatment. For block 2 (n=119), guidelines and/or standardized order sets (SOSs) were used supported by intensive clinical case management (ICCM) (full variance tracking with concurrent feedback and reminders). The ICCM interventions were conducted by resident physicians. For block 3 (n=115), all orders were written with guidelines and/or SOSs but without ICCM. Results: The mean±SD time to clinical stability was not significantly different between the groups (block 1, 3.3±1.4 days; block 2, 3.2±1.2 days; and block 3, 3.4±1.3 days). The mean LOS was significantly lower in block 2 (5.3±3.5 days) than in blocks 1 (8.8±4.4 days) (P<.001) and 3 (7.3±3.9 days) (P<.01) and significantly lower in block 3 than in block 1 (P=.05). Time to change to oral antibiotics was earlier in block 2 (3.7±0.9 days) than in blocks 1 and 3 (5.7±2.4 and 5.0±1.9 days, respectively) (P<.001). The mean time from clinical stability to hospital discharge was significantly shorter for block 2 (2.1±2.2 days) than for blocks 1 (5.3±4.4 days) (P<.001) and 3 (4.9±4.2 days) (P<.001). Patients in block 2 had a greater proportion with progressive ambulation (P<.001), pneumococcal (P<.001) or influenza vaccination (P<.01), deepvenous thrombosis prophylaxis (P=.01), and smoking cessation counseling (P=.01). There was no significant difference between the blocks in mortality or hospital readmission rate. Conclusions: The combined intervention of SOS plus ICCM led to a substantial reduction in LOS while maintaining quality of care. The main effect occurred by reducing the time from clinical stability to discharge, which appeared to be the key "modifiable" process of care adding to a prolonged LOS.

Original languageEnglish (US)
Pages (from-to)1664-1669
Number of pages6
JournalArchives of Internal Medicine
Volume167
Issue number15
DOIs
StatePublished - Aug 13 2007
Externally publishedYes

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Case Management
Length of Stay
Pneumonia
Guidelines
Quality of Health Care
Human Influenza
Vaccination
Costs and Cost Analysis
Patient Readmission
Smoking Cessation
Walking
Counseling
Thrombosis
Anti-Bacterial Agents
Delivery of Health Care
Physicians
Mortality

ASJC Scopus subject areas

  • Internal Medicine

Cite this

Fishbane, S., Niederman, M. S., Daly, C., Magin, A., Kawabata, M., De Corla-Souza, A., ... Parker, S. (2007). The impact of standardized order sets and intensive clinical case management on outcomes in community-acquired pneumonia. Archives of Internal Medicine, 167(15), 1664-1669. https://doi.org/10.1001/archinte.167.15.1664

The impact of standardized order sets and intensive clinical case management on outcomes in community-acquired pneumonia. / Fishbane, Steven; Niederman, Michael S.; Daly, Colleen; Magin, Adam; Kawabata, Masateru; De Corla-Souza, André; Choudhery, Irum; Brody, Gerald; Gaffney, Maureen; Pollack, Simcha; Parker, Suzanne.

In: Archives of Internal Medicine, Vol. 167, No. 15, 13.08.2007, p. 1664-1669.

Research output: Contribution to journalArticle

Fishbane, S, Niederman, MS, Daly, C, Magin, A, Kawabata, M, De Corla-Souza, A, Choudhery, I, Brody, G, Gaffney, M, Pollack, S & Parker, S 2007, 'The impact of standardized order sets and intensive clinical case management on outcomes in community-acquired pneumonia', Archives of Internal Medicine, vol. 167, no. 15, pp. 1664-1669. https://doi.org/10.1001/archinte.167.15.1664
Fishbane, Steven ; Niederman, Michael S. ; Daly, Colleen ; Magin, Adam ; Kawabata, Masateru ; De Corla-Souza, André ; Choudhery, Irum ; Brody, Gerald ; Gaffney, Maureen ; Pollack, Simcha ; Parker, Suzanne. / The impact of standardized order sets and intensive clinical case management on outcomes in community-acquired pneumonia. In: Archives of Internal Medicine. 2007 ; Vol. 167, No. 15. pp. 1664-1669.
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AU - Magin, Adam

AU - Kawabata, Masateru

AU - De Corla-Souza, André

AU - Choudhery, Irum

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N2 - Background: Community-acquired pneumonia is a frequent cause for hospital admission that results in significant costs to the health care system. The length of hospital stay (LOS) affects costs as well as risk for nosocomial medical complications. The purpose of this study was to test whether the addition of intensive clinical case management to clinical guidelines could lead to a reduction in LOS that was not achievable by guidelines alone, while maintaining quality of care. Methods: Patients were studied in 3 sequential blocks at a single hospital from November 2002 to February 2005. Block 1 patients (n=110) were given conventional treatment. For block 2 (n=119), guidelines and/or standardized order sets (SOSs) were used supported by intensive clinical case management (ICCM) (full variance tracking with concurrent feedback and reminders). The ICCM interventions were conducted by resident physicians. For block 3 (n=115), all orders were written with guidelines and/or SOSs but without ICCM. Results: The mean±SD time to clinical stability was not significantly different between the groups (block 1, 3.3±1.4 days; block 2, 3.2±1.2 days; and block 3, 3.4±1.3 days). The mean LOS was significantly lower in block 2 (5.3±3.5 days) than in blocks 1 (8.8±4.4 days) (P<.001) and 3 (7.3±3.9 days) (P<.01) and significantly lower in block 3 than in block 1 (P=.05). Time to change to oral antibiotics was earlier in block 2 (3.7±0.9 days) than in blocks 1 and 3 (5.7±2.4 and 5.0±1.9 days, respectively) (P<.001). The mean time from clinical stability to hospital discharge was significantly shorter for block 2 (2.1±2.2 days) than for blocks 1 (5.3±4.4 days) (P<.001) and 3 (4.9±4.2 days) (P<.001). Patients in block 2 had a greater proportion with progressive ambulation (P<.001), pneumococcal (P<.001) or influenza vaccination (P<.01), deepvenous thrombosis prophylaxis (P=.01), and smoking cessation counseling (P=.01). There was no significant difference between the blocks in mortality or hospital readmission rate. Conclusions: The combined intervention of SOS plus ICCM led to a substantial reduction in LOS while maintaining quality of care. The main effect occurred by reducing the time from clinical stability to discharge, which appeared to be the key "modifiable" process of care adding to a prolonged LOS.

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