Published in the March 2004 issue of Today’s Hospitalist
In the fight against community-acquired pneumonia (CAP), timing is everything. The sooner patients with pneumonia receive antibiotics, the smoother their recovery will go, making everyone happy.
The problem is that in too many instances, CAP patients don’t receive treatment as quickly as possible. In many hospitals, for example, the conventional wisdom calls for antibiotics to be administered within eight hours of admission, a timeframe that many experts say is too slow.
As a result, public health officials and hospitals throughout the country are looking at ways to speed up “and generally improve “the way that pneumonia patients are treated.
Some of these strategies emphasize the basics, such as identifying “and treating “community-acquired pneumonia patients as early as possible, often within four hours. Several national groups last year formally revised recommendations and called on physicians to treat CAP patients within that timeframe.
Led by hospitalist services, some hospitals are going even further and finding ways to reach out to CAP patients before they ever step foot into a hospital. The goal is to start patients on antibiotic therapy early enough to help keep them from ever having to enter the hospital.
Here’s a look at how CAP treatment is changing to emphasize timely treatment, and how some hospitalists are focusing on the timing of drug therapy to improve their patients’ care.
Room for improvement
Community-acquired pneumonia is a major health problem in the United States. Each year, 5.6 million adults are diagnosed with the condition, and 1.7 million patients wind up in the hospital. While pneumonia and influenza are the seventh leading cause of death in this country, they take a particularly high toll on elderly patients.
Scott Flanders, MD, director of the hospitalist program at the University of Michigan in Ann Arbor, gives the nation’s CAP programs a “B” grade. “National data suggest we do a fair job,” he explains, “with an opportunity to move up to an A.”
To reach that level, Dr. Flanders says, hospitals need to start by delivering drugs to pneumonia patients faster. Until recently, the consensus was that patients who entered the hospital with pneumonia needed intravenous antibiotics within eight hours.
But recent data suggest that cutting that window in half could save thousands of lives a year. As a result, the Infectious Diseases Society of America last year began recommending that IV antibiotics start flowing within four hours of admission.
A 2003 report by the Antibiotic Selection for Community-Acquired Pneumonia (ASCAP) panel endorsed the four-hour window. Gideon Bosker, MD, an emergency medicine specialist at Yale University in New Haven, Conn., who chaired the panel, estimates that “fewer than 50 percent” of patients are treated so promptly. He says that timing is a key area where hospitals can improve how they treat CAP.
Dr. Bosker adds that delays in treating CAP patients typically involve bottlenecks in patient flow in emergency rooms. In addition, some physicians may simply not recognize that clinical outcomes for pneumonia are closely tied to the promptness of antibiotic administration.
“The motivation to provide prompt antibiotic administration may not be as strong as it is for other conditions” like meningitis, he adds.
The 16 hospitalists working at the Cleveland Clinic Foundation see roughly 1,200 cases of community acquired pneumonia each year. That’s second in volume only to congestive heart failure.
Franklin Michota, MD, head of the hospitalist program at Cleveland Clinic, says there are two keys to a successful and efficient CAP program. The first is standardization in terms of timely treatment and drug therapy. “The more that we’re able to standardize our care, the better it will be,” he says.
Uniformity starts at the front door. As soon as a physician suspects pneumonia, the hospital’s clock starts running. “We look at a benchmark of getting antibiotics started within four hours,” Dr. Michota says.
Patients are assessed for whether they need supplemental oxygen. (Most do.) Blood is then drawn for cultures, which can help determine the length of antibiotic therapy. Physicians also check for other serious health problems that can complicate infections, like diabetes. When all that’s done, patients are sent to the ward.
Once patients reach the ward, the standardization continues. Nurses focus on making patients mobile as soon as possible. They also give patients pamphlets about the drugs they’re taking to help them comply with their therapies.
(The organization’s hospitals use an online service from Lexi-Comp that can provide information about drug-drug and drug-food interactions with the antibiotics that make up a particular regimen.)
Dr. Michota says that most patients improve within 48 hours. If they don’t, they’re re-evaluated for the presence of germs not covered by the drugs they’re taking, or they’re evaluated for underlying complications that were missed during admission.
Another critical element of effective CAP care? Knowing what bugs are lurking in the community. “It’s important that we understand locally” what’s causing infections, Dr. Michota says.
Failing to keep close surveillance on the strains of bacteria at the hospital level will stymie effective antibiotic coverage. It will also increase the risk of promoting drug resistance by over-treating with broad-spectrum medications.
The infectious agents to blame for pneumonia go undetermined in more than half of all cases. When the germ is identified, however, it’s usually S. pneumoniae, a microbe that the CDC links to between 100,000 and 135,000 pneumonia admissions each year.
S. pneumoniae is the top dog of the six organisms that are the leading causes of pneumonia. The rest of the field includes H. influenzae, M. catarrhalis and a string of “atypical” microbes that include M. pneumoniae, C. pneumoniae and L. pneumophila.
The bad news is that S. pneumoniae is showing increasing signs of resistance to antibiotics. Today, four in 10 cases of pneumonia caused by the bug resist at least one drug. Another 15 percent shrug off three or more antibiotics.
Targeting drug therapies
David Bowman, MD, chief of staff at St. Mary’s Hospital in Tucson, Ariz., says that pneumonia is fairly common in the older people he treats, many of whom moved to the southwest because of lung problems. Nonetheless, St. Mary’s was recently singled out by the Catholic Consortium of hospitals for its outstanding CAP program.
Standardization is the key to the clinic’s success, says Dr. Bowman, who is also executive director of the Tucson division of IPC, a national hospitalist firm. St. Mary’s has limited its CAP drugs to three: a combination regimen of ceftriaxone/azithromycin, and one-drug therapy with levofloxacin.
Some doctors might balk at such a limited formulary, but Dr. Bowman says he looks at it another way: “You’re not practicing cookbook medicine by doing something that is most right. This is what’s working.”
Of course, a hospital’s roster of antibiotics is next to worthless if the drugs aren’t administered in a timely manner. “The medications are readily available to the ER staff and there is minimal delay in coming out of a central pharmacy,” Dr. Bowman says. That allows them to give the first, critical dose as quickly as possible upon seeing a pneumonia patient.
He says that the strategy has been effective. Between July and September of 2003, CAP patients on average received antibiotics within 215 minutes “three and a half hours “after arriving at the hospital. While that range fits comfortably within the four-hour window recommended by the IDSA, Dr. Bowman notes that many CAP patients are starting antibiotic therapy two hours from the time of sign-in.
The results have been encouraging. Last year, Dr. Bowman reports, length of stay for CAP patients at St. Mary’s averaged 4.1 days, while mortality averaged 1.3 percent.
Looking beyond the hospital
St. Mary’s also uses another strategy when treating CAP, one that is becoming popular among some hospitals: working with outpatient physicians to help minimize or eliminate hospitalization altogether.
St. Mary’s, for example, works to convince area doctors to start antibiotic therapy before their patients go to the emergency room. “If you can give patients a dose before you send them over to admissions, at least they’ve got the most important treatment done in the office,” Dr. Bowman says.
While pneumonia is a major source of hospital admissions, research has shown that many “if not most “patients don’t need to be hospitalized while they receive antibiotic treatment. Evidence shows that home-based antibiotic programs can provide excellent care for lung infections (as well as other illnesses) while saving hospitals thousands of dollars per patient in the process.
Lawrence Dall, MD, a hospitalist at Midwest Hospital Specialists in Kansas City, Mo., runs such a program. In 1999, Dr. Dall and his colleagues began a study that compared hospital care for CAP with in-home treatment. Patients with all but the most severe forms of pneumonia were treated at home with once-daily infusions of combination antibiotic therapy.
He says that the results of his research were clear. “There was no mortality, no nosocomial infections,” Dr. Dall explains.
What’s more, nearly all of the 92 patients who participated in the trial said they would undergo their care at home again if given the chance. “It was received very well,” he says.
The bottom line looked good, too. The average cost of treating a pneumonia patient at home was about $3,200, an amount that reduced inpatient care between $2,800 and $4,300. Based on that success, Midwest has fully embraced outpatient antibiotic therapy for community-acquired pneumonia and certain other infections such as cellulitis.
Dr. Dall stresses that one of the once “daily antibiotics should be a cephalosporin that can penetrate the central nervous system to prevent meningitis. The second antibiotic does not have to be given intravenously and can be taken orally. The course should run for at least three days, he adds.
While he highly recommends home-based CAP therapy, he notes that setting up the program requires serious effort. He and his colleagues worked with home health providers “registered nurses and infusion specialists, in particular “for the better part of a year before they sent their first pneumonia patient home for care.
Outpatient CAP therapy must also have an aggressive home breathing care program in place, and a full regiment of nebulizers, bronchodilators and supplemental oxygen is critical. Respiratory therapists must also be ready to visit patients within four hours of their arrival back at home, even if that occurs in the middle of the night.
Communication is another issue. Dr. Dall tells home providers to refer all questions to the doctors in charge of the pneumonia program, not the patients’ primary care physician, while patients were undergoing treatment.
Perhaps just as important, Dr. Dall says, physicians must correctly grade the severity of patients’ lung infections. His group uses the Fine classification “described in a 1997 New England Journal of Medicine article “to sort patients into one of five categories. A ranking of 5 represents the most serious cases, while a grade of 1 represents the mildest.
Patients who fall into the first four tiers are eligible for the outpatient program; those in the fifth tier must remain in the hospital. “If you don’t learn that classification,” Dr. Dall says, “you’re going to have a death pretty darn quickly.”
Dr. Dall’s program is far from the only one looking to community physicians for help treating pneumonia.
Cogent Healthcare Inc., an inpatient care firm in Irvine, Calif., says that by using the pneumonia severity index (PSI) to assess pneumonia severity, its physicians can cut unnecessary admissions by 18%. Patient care is better, says Nanveet Kathuria, MD, Cogent’s national medical director, and the hospital saves between $500 and $1,000 per patient.
“We are a company that provides in-hospital care,” he explains. “Part of that is being a lot more judicious about who actually needs to be admitted vs. who can be treated on an outpatient basis.”
To streamline the admissions process, Cogent gives its doctors handheld computers loaded with software to help them make the proper diagnosis. All patients “not just those with pneumonia “are called at home after discharge to make sure they’re taking their medication properly, that they’re seeing their primary care physician, and they have supplemental oxygen if they require it, Dr. Kathuria says.
While Dr. Kathuria says that Cogent’s high-tech approach has helped its hospitalists better treat CAP, some decidedly low-tech approaches can make a difference. Experts note that simply urging patients to regularly wash their hands seems to be effective at reducing the spread of pneumonia.
And Dr. Flanders from the University of Michigan agrees that most hospitals could do much better in two basic areas: promoting pneumococcal and flu vaccines at discharge, and urging patients to quit smoking.
While these vaccinations can help reduce the incidence of lung infections and the opportunistic infections that strike when patients’ immune systems are flagging, they are not widely administered. Dr. Flanders points to a 2003 study in the Journal of the American Medical Association that found that only 24 percent of Medicare beneficiaries with CAP were screened for pneumococcal vaccine at discharge. The figure was similarly dismal for the flu shot.
While the study didn’t examine counseling for smoking cessation, Dr. Flanders notes that current guidelines call only for hospitalists to counsel patients about the importance of quitting, not to recommend specific cessation programs or prescribe medication.
Dr. Flanders, however, says that guidelines in the works from two large organizations “the American Thoracic Society and the Infectious Diseases Society of America “may give CAP care a boost. He says that the two groups have agreed to release joint guidelines that will address the full gamut of CAP care, from antibiotic treatment to admission criteria, diagnostic testing and vaccination policies. “I think this will be very helpful for physicians,” Dr. Flanders says.
Adam Marcus is a freelance writer specializing in health care. He lives in New York.