L. Pulver

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.

Current discharge management of acute coronary syndromes: baseline results from a national quality improvement initiative.

Background: Evidence–practice gaps exist in the continuum of care for patients with acute coronary syndromes (ACS), particularly at hospital discharge.

Management of Acute Coronary Syndromes at Hospital Discharge: Do Targeted Educational Interventions Improve Practice Quality?

&NA; Evidence‐based guidelines exist for the management of patients with acute coronary syndromes (ACS), yet adherence is suboptimal. The Discharge Management of Acute Coronary Syndrome project used a quality improvement approach, with targeted intervention strategies to optimize: prescription of guideline‐recommended medications; education regarding lifestyle modifications, including cardiac rehabilitation (CR); and communication between hospital staff, patients, and general practitioners. Hospitals across Australia participated in a quality improvement cycle of audit, feedback, intervention, and reaudit. Interventions involved educational meetings, academic detailing and point‐of‐care reminders, and feedback of baseline audit results. Outcome measures included prescription of guideline‐recommended medications, referral to CR, and documentation and communication of management plan. At baseline, 49 hospitals recruited 1,545 patients, and postintervention, 45 hospitals remained active in the project and recruited 1,589 patients. Three thousand and thirty‐four hospital staff attended group education or academic detailing sessions. Postintervention, there was a significant increase in the prescription of all four guideline‐recommended medications (69% vs. 57%; p<.0001); short‐acting nitrates (68% vs. 56%; p<.0001); and documented referral to CR (68% vs. 57%; p<.0001). There were significant increases in documented discharge medication counselling, smoking cessation counselling, and communication of management plans. Targeted educational interventions used as part of a quality improvement cycle can enhance adherence to evidence‐based guidelines for the management of patients with ACS.

Comparison of prescribing criteria in hospitalised Australian elderly

The Beers criteria (2003) and McLeod criteria (1997) have been applied internationally to quantify inappropriate prescribing in elderly populations. Similarly, guidelines have been published locally by the National Prescribing Service (NPS). Objective This study aimed to adapt, evaluate and compare the utility of these three established criteria in measuring prescribing appropriateness in a sample of hospitalised elderly patients. Methods Initial refinement of the criteria produced versions applicable to Australian practice. Inpatient records of 202 patients aged 65 years or older in six wards of the Princess Alexandra Hospital, Brisbane, Australia, were reviewed using the adapted criteria. ‘Potentially inappropriate’ prescribing was descriptively analysed using relevant denominators. Results The adapted criteria collectively listed 70 ‘potentially inappropriate’ medicines or drug groups and 116 ‘potentially inappropriate’ prescribing practices. Patients (mean age 80.0; SD=8.3 years) were prescribed, a median of eight medicines (SD=4.0). At least one ‘potentially inappropriate’ medicine was identified in 110 (55%) patients. ‘Potentially inappropriate’ prescribing practices averaged 1.1 per patient (range 1-6). The adapted Beers criteria identified more ‘potentially inappropriate’ medicines/practices (44%, 101/232) than the McLeod criteria (41%) and NPS criteria (16%). Aspirin, benzodiazepines, beta-blockers and dipyridamole were most commonly identified. Conclusion The Beers and McLeod criteria, developed internationally, required considerable modification for local prescribing. The three criteria differed in their focus and approaches, such that development and validation of national criteria, using the key features of these models, is recommended. There is potential to apply validated guidelines in clinical practice and review of prescribing, but only to supplement clinical judgement.

Glycopeptide prescribing in an Australian tertiary paediatric hospital.

Objective: To assess the extent and appropriateness of glycopeptide use in a tertiary Australian Paediatric hospital.

Drug utilization review across jurisdictions – a reality or still a distant dream?

ObjectiveThere is a perception that many drug usage evaluations do not widely influence prescribing behaviour. The aim of this study was to critically evaluate recent journal articles which fit the Medline definition for Drug Utilization Review (DUR) and which also cover multiple healthcare sites.MethodsPubMed (National Library of Medicine, NLM) (2003, 2004) was searched using the MeSH topic ‘drug utilization’. Retrieved studies were evaluated to ascertain those describing a DUR (measuring drug use against specific criteria). These were subdivided according to whether the DUR was conducted at one site or across many. The multi-centre DURs were critically reviewed, including evaluating whether all phases of a quality cycle were completed and determining aspects of design such as whether the study was prospective or retrospective, any interventions conducted and provision of feedback.ResultsA total of 646 unique articles were retrieved. Of these, 495 (77%) did not meet the definition for DUR, while 151 (23%) articles did. Thirty-five (5%) described English language multi-centre DURs; ethics approval was obtained in ten of these and 18 were carried out retrospectively. In all 35 studies some comparator or standard was used, but only eight conducted an intervention and only three provided feedback to the prescribers.ConclusionMost DURs were not conducted across a number of centres. Of the recent published multi-centre DURs most presented only an initial audit and did not complete the quality cycle with feedback, intervention and re-audit. To widely influence prescribing behaviour, the full cycle is required with involvement of as many sites as possible to achieve improvements across many jurisdictions.

Innovation in hospital quality improvement activities--acute postoperative pain management (APOP) self-help toolkit audits as an example.

&NA; It is often difficult to maintain quality improvement change. Many behavioral strategies have been used to improve uptake of new practices and knowledge. One effective way of changing medication prescribing is audit and feedback with specific educational feedback. The challenge however is to maintain ongoing quality improvement activities. In Australia, unique downloadable “toolkits” are now available to assist hospitals to maintain prescribing quality improvement activities. The first designed to improve the management of acute postoperative pain (APOP toolkit) has been piloted. The toolkit includes data collection and educational tools, an automated feedback report on key indicators, with complete instructions for use. The APOP toolkit has been used in 73 hospitals, in two facilitated “snapshot” audits. There was continued improvement in performance, assessed by increases in the percentage of patients with measured pain and sedation scores and in those with documented pain management plans at discharge, compared with earlier APOP project audits. Using this example of the APOP toolkit and “snapshot” audits, we have now demonstrated that hospitals nationwide are able to undertake quality improvement activities voluntarily to maintain optimal performance. Encouragement, guidance, and availability of ready‐made tools developed by a national team facilitate opportunities for ongoing quality improvements.

The Queensland experience of participation in a national drug use evaluation project, Community-acquired pneumonia – towards improving outcomes nationally (CAPTION)

BackgroundMulticentre drug use evaluations are described in the literature infrequently and usually publish only the results. The purpose of this paper is to describe the experience of Queensland hospitals participating in the Community-Acquired Pneumonia Towards Improving Outcomes Nationally (CAPTION) project, specifically evaluating the implementation of this project, detailing benefits and drawbacks of involvement in a national drug use evaluation program.MethodsEmergency departments from nine hospitals in Queensland, Australia, participated in CAPTION, a national quality improvement project, conducted in 37 Australian hospitals. CAPTION was aimed at optimising prescribing in the management of Community-Acquired Pneumonia according to the recommendations of the Australian Therapeutic Guidelines: Antibiotic 12th edition. The project involved data collection, and evaluation, feedback of results and a suite of targeted educational interventions including audit and feedback, group presentations and academic detailing.A baseline audit and two drug use evaluation cycles were conducted during the 2-year project. The implementation of the project was evaluated using feedback forms after each phase of the project (audit or intervention). At completion a group meeting with the hospital coordinators identified positive and negative elements of the project.ResultsEvaluation by hospitals of their participation in CAPTION demonstrated both benefits and drawbacks. The benefits were grouped into the impact on the hospital dynamic such as; improved interdisciplinary working relationships (e.g. between pharmacist and doctor), recognition of the educational/academic role of the pharmacist, creation of ED Pharmacist positions and enhanced involvement with the National Prescribing Service, and personal benefits. Personal benefits included academic detailing training for participants, improved communication skills and opportunities to present at conferences. The principal drawback of participation was the extra burden on already busy staff members.ConclusionA national multicentre drug use evaluation project such as CAPTION allows hospitals which would otherwise not undertake such projects the opportunity to participate. The Queensland arm of CAPTION demonstrated benefits to both the individual participants and their hospitals, highlighting the additional value of participating in a multicentre project of this type.