A comprehensive approach to achieving near 100% compliance with The Joint Commission Core Measures for pneumonia antibiotic timing

Background

Adherence to The Joint Commission (TJC) Core Measures benchmarks is required for hospital accreditation, and data are publicly reported as an indication of hospital quality. Published approaches to date for adhering to the pneumonia antibiotic timing (PN5c) Core Measure have shown moderate to limited success in reaching high levels of compliance.

Objective

The objective of the study was to evaluate the effectiveness of a 3-phased intervention directed at improving compliance with TJC pneumonia antibiotic administration within the 6-hour requirement (PN5c) in an academic urban emergency department.

Methods

A 3-phase interventional study with retrospective analysis of contemporaneous data collection during a 57-month period ending September 2009 was performed. Phase 0 was baseline, phase 1 was physician evaluation at triage, phase 2 was implementation of a specific pneumonia screening tool and pathway, and phase 3 was implementation of an emergency department electronic medical record system that facilitates removing subjects with “diagnostic uncertainty” from consideration. Main outcome measure was the proportion of patients receiving antibiotics within 6 hours among those meeting PN5c criteria. Mean times to antibiotics and percentage of compliance with PN5c were compared for each phase.

Results

Percentage of compliance with PN5c increased from a baseline of 77% through each of the 3 phases: 85%, 91%, and 95%, respectively (Cochran-Armitage trend, P < .001). Mean time to antibiotic administration decreased from a baseline of 285 minutes with each successive intervention to 224, 189, and 169 minutes, respectively (linear regression, P < .001).

Conclusion

Implementation of a structured intervention that includes early physician triage, a screening tool for immediate imaging and reporting, and electronic record-facilitated compliance review effectively improves TJC PN5c compliance to high levels.