recommendations
Many national and local initiatives have tried to improve the quality of CAP management (248, 250, 272). It has been agreed that there is a positive correlation between adherence to the recommended guideline and reduced LOS and mortality rate. The main effort has been to actively implement the guideline. Studies showed that active implementation of the CAP guideline can significantly increase the rate of adherence. Reported rates of improvement in concordance with the guideline ranged from 6.2% to 28% (250, 257, 272, 273).
It is not uncommon to perform more than one strategy in order to implement CAP guidelines. In one meta-analysis study, it was found that the intervention strategies most often used were educational meetings (63%) and dissemination of written materials (78%) (274). A combination of these two strategies was used in 52% of the studies. Most intervention studies resulted in a modest improvement in the adherence rate to the guideline, except in the case of audit and feedback
46 strategy, which when used alone resulted in either a lack of or only modest improvement (274). Increasing strategies to be multifaceted for implementing CAP guidelines in an institution has been associated with an increasing utilisation of the recommended guidelines. An American large randomised controlled study showed that the adherence rate in those hospitals, where high intense multifaceted strategies were performed, was significantly higher than those in hospitals where only low or moderate intense strategies were performed (65.6%, 29.3%, and 30.7%, respectively) (275, 276).
Some strategies might be more suited to a particular healthcare setting, such as one-on-one academic detailing which might not be practical in busy areas such as ED, where it could take 12 minutes on average (277). Similarly, ED might not be a good place to conduct one-on-one
education due to the small area available. In contrast, group discussion might be more accepted in a busy department (277).Table 1.9 summarises the interventions that have been shown to improve implementation of recommended CAP guidelines:
47
Table 1.9: Summary of the interventions of recommended CAP guidelines that have been used to improve implementation (274).
Intervention Intervention methods
Educational
Dissemination of written materials (e.g. mailing)
Educational meetings (e.g. grand rounds)
Academic detailing (i.e. one-on-one meeting between prescriber and trained medical staff)
Reminders
Patient chart reminder (i.e. standard treatment in the chart)
Electronic reminder (i.e. appearance of the recommended guideline when ordering)
Pre-printed forms
Undefined reminder (e.g. potters or tag card) Local opinion leader
Audit and feedback
(i.e. feedback of the performance regarding adherence to the guideline throughout period of time)
Multi-
participation
Multidisciplinary team (team from different specialities)
Local consensus process (i.e. including prescribers in the discussion regarding the guideline)
Patient mediated intervention (i.e. third party intervention such as by a pharmacist)
External guiding
Clinical pathway
Standing order (e.g. preauthorised order set)
Formulary adaption (e.g. limiting antibacterial choices)
Structural Computerised system (i.e. decision support)
Organisational (e.g. selected antibiotic stock at the ward) Other recorded
factors
Quality improvement organisations (i.e. local or external organisations that focus on the improvement of CAP outcome)
Interventions among Australian hospitals
Several efforts and interventions have been made among Australian hospitals to improve the quality of antibiotics use for the management of CAP. One of the Australian programmes for improving the quality of antibiotics use was the Community-Acquired Pneumonia: Towards Improving Outcome Nationally (CAPTION) (250). The programme is aimed at improving the appropriate use of antibiotics in CAP through encouraging physicians to adhere to the national guideline. EDs around Australia (n=26) participated in the programme. The first step of CAPTION was to collect baseline data to measure the rate of adherence to the guideline before any
48 1- One-on-one academic detailing
2- General slide presentation for the feedback of local data on guideline concordance, and an education session about the best practice management of CAP according to the guideline 3- Supply letters to the prescribers
4- Wall posters
5- Tag cards that included PSI variables to be measured
The overall improvement in the adherence to the guideline was moderate, with adherence rates rising from 20% to 30%. However, a limitation of the study was the low number of patients (20 patients in each hospital).
Another intervention was made by one Australian teaching hospital to improve the use of the CAP guideline (248). In this intervention, the guidelines were made easily accessible in the ED and throughout the hospital computer system. Furthermore, physicians were encouraged to calculate and document the PSI on the medical record and to use that to guide patient admission and the use of recommended antibiotics. That study showed that even though it was difficult to apply the PSI in the ED, concordance to the recommended guideline was 20% more when PSI was documented. However, one limitation of the study was the lack of baseline data to measure the effect of the intervention.
The type of intervention could significantly make a difference in the adherence rate. For example, the use of a computer support system could be more effective than academic detailing to implement a guideline. These two strategies were implemented in one Australian hospital in two different periods of time (148). During the first period, one-on-one academic detailing was utilised. In the second period, a computerised system for antibiotic prescribing, where the guideline’s recommendations came up on screen at the time of ordering was implemented. The transferable website included tools to calculate the PSI variables in order to guide the admission decision (outpatient vs inpatient), and CURB65 variables in order to decide whether the patient needed ICU
49 admission or not. The website also included recommendations about appropriate antibiotics,
duration, time to switch therapy from IV to oral, and the relevant literature that supported the recommendations. This strategy increased awareness of the guideline and hence adherence. When compared to the academic detailing strategy, the rate of adherence was higher when a computer support system was utilised (68.7% and 89.7%, respectively).