Giving Antibiotics Early:
                        -------------------------

This thread started about gram stains and their utility versus futility...but
"somewhere ran into whether "early" antibiotics were of benefit or not.  As part
of the national Peer Review Systems program, our hospital began a pneumonia
clinical pathway last year.  In addition to getting some questionable labs, our
main role in the ED was helping start antibiotics within 4 hours (since evne
with a CQI push it takes an average of 8 hours to get antibiotics started on the
floor).  We have seen our mortality half and our ave LOS decrease by more than a
day.  In unpublished results from Peer Review Systems handout/ follow up
presentation to us, they claim a decrease in Medicare patient population
mortality in Ohio from 11% to 5% in institutions implementing the program.
        Two references regarding the pathway implementation are:

1.  McGarvey R; "Pneumonia Mortality Reduction and QI in a Community Hospital".
QRB; April 1993, 124-129.
        Forbes Health Care Systems found after 18 months that mortality decreased
from 10.2 to 6.8% and LOS was down 1.3 days at a savings of $943 per patient.

2.  Rollins D;  "Improving antibiotic delivery time to pneumonia patients: CQI
in action".  J of Nursing Care Quality; 1994, 8(2): 22-31.
        Providence Med Center ED  decreased time to antibiotic administration
from 6.8 to 3.6 hours resulting in a 1 day decreased LOS and $109K savings in
one year.

--Joe Bocka, Cambridge, OH

        Thanks for the references Joe.  I was able to pull both abstracts
today and I'll, try to get the original articles this week.  A few
preliminary observations, however.  The Rollins study (1) appears to
imply that the cost savings were a result of judicious (but not
necessarily) prompt antibiotic therapy.  As far as Mcgarvey's article is
concerned (2), they seem to have implemented several simultaneous, possibly
confounding, changes which led to the decreased mortality. I'm sure that
QRB is an outstanding journal in it's own right, but don't you think that
if these folks were able to demonstrate a near halving in mortality from
prompt antibiotic therapy in community acquired pneumonia that
publication in NEJM would have been more appropriate?  After all, I am
not aware of anyone else who has been able to duplicate these results.
This is a result that is difficult to prove even in cases of early
treatment of lethal infections, such as bacterial meningitis much less
community acquired pneumonia.  I remain very skeptical.

H. Louzon MD

(1)
Rollins D, Thomasson C, Sperry B
Improving antibiotic delivery time to pneumonia patients: continuous quality
improvement in action.
J Nurs Care Qual 1994 Jan;8(2):22-31

A multidisciplinary team simplified the process of antibiotic delivery to
patients admitted with community-acquired pneumonia and successfully
implemented key changes that resulted in improved clinical practice and
patient satisfaction at Providence Medical Center. Within 6 months of
implementing an emergency room preadmission procedure, an antibiotic
treatment protocol, and a sputum collection protocol, the average antibiotic
initiation time dropped from 6.8 hours to 3.6 hours. Recommendations made
for antibiotic selection and dosing led to a cost savings of over $109,000
per year. Highlighted in this article are several quality improvement tools,
as well as practical tips and advice on effective team building.

(2)
McGarvey RN, Harper JJ
Pneumonia mortality reduction and quality improvement in a community
hospital.
QRB Qual Rev Bull 1993 Apr;19(4):124-30

Rather than explain adverse results on the basis of flawed data, a
physician-directed quality improvement program was initiated to improve the
delivery of care to patients admitted to Forbes Health System (Monroeville,
Penn) with community-acquired pneumonia. Following the introduction of
standardized physician orders and modification and elimination of
inefficient processes of care, the mortality rate for this infection
decreased from 10.2% to 6.8%. This initial exposure to the quality
improvement process led to the participation of the medical staff in other
related clinical and support service initiatives. In addition, Forbes and
its clinical partners are now better positioned to respond to increasing
government, managed care, and consumer inquiries relating to cost and
quality outcomes. Finally, this positive experience facilitated the
organization's transition from inspection-based quality assessment to
quality improvement activities, which should assist in efforts to meet or
exceed new accreditation standards.