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The impact of standardized order sets and intensive clinical case management on outcomes in community-acquired pneumonia.
Arch Intern Med. 2007 Aug 13-27; 167(15):1664-9.AI

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), 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.

Authors+Show Affiliations

Winthrop University Hospital, Mineola, New York, USA. sfishbane@winthrop.orgNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article

Language

eng

PubMed ID

17698690

Citation

Fishbane, Steven, et al. "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, 2007, pp. 1664-9.
Fishbane S, Niederman MS, Daly C, et al. The impact of standardized order sets and intensive clinical case management on outcomes in community-acquired pneumonia. Arch Intern Med. 2007;167(15):1664-9.
Fishbane, S., Niederman, M. S., 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, 167(15), 1664-9.
Fishbane S, et al. The Impact of Standardized Order Sets and Intensive Clinical Case Management On Outcomes in Community-acquired Pneumonia. Arch Intern Med. 2007 Aug 13-27;167(15):1664-9. PubMed PMID: 17698690.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - The impact of standardized order sets and intensive clinical case management on outcomes in community-acquired pneumonia. AU - Fishbane,Steven, AU - Niederman,Michael S, AU - Daly,Colleen, AU - Magin,Adam, AU - Kawabata,Masateru, AU - de Corla-Souza,André, AU - Choudhery,Irum, AU - Brody,Gerald, AU - Gaffney,Maureen, AU - Pollack,Simcha, AU - Parker,Suzanne, PY - 2007/8/19/pubmed PY - 2007/10/3/medline PY - 2007/8/19/entrez SP - 1664 EP - 9 JF - Archives of internal medicine JO - Arch Intern Med VL - 167 IS - 15 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), 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. SN - 0003-9926 UR - https://www.unboundmedicine.com/medline/citation/17698690/The_impact_of_standardized_order_sets_and_intensive_clinical_case_management_on_outcomes_in_community_acquired_pneumonia_ L2 - https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/10.1001/archinte.167.15.1664 DB - PRIME DP - Unbound Medicine ER -