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The Impact of Standardized Order Sets and Intensive Clinical Case Management on Outcomes in Community-Acquired Pneumonia
Steven Fishbane, MD;
Michael S. Niederman, MD;
Colleen Daly, MD;
Adam Magin, MD;
Masateru Kawabata, MD;
André de Corla-Souza, MD;
Irum Choudhery, MD;
Gerald Brody, MD;
Maureen Gaffney, RPAC;
Simcha Pollack, PhD;
Suzanne Parker, RN
Arch Intern Med. 2007;167(15):1664-1669.
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), deep-venous 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.
Author Affiliations: Winthrop University Hospital, Mineola, New York (Drs Fishbane, Niederman, Daly, Magin, Kawabata, de Corla-Souza, Choudhery, and Brody and Mss Gaffney and Parker), and St John's University, Queens, New York (Dr Pollack).
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