The NICE pneumonia guidance (CG191) makes recommendations concerning best practice in the management of community-acquired pneumonia, but implementation is challenging. A Respiratory Infections Team was developed at the Royal Derby Hospital, comprising three specialist nurses supported by a respiratory consultant and antimicrobial pharmacist.
Its aims were to review daily all patients admitted to hospital with CAP, and to a) improve concordance with the NICE pneumonia guidelines, in particular with reference to timely diagnosis and appropriate treatment, and ; b) identify patients with low severity CAP for remote outpatient management with early supported discharge; and c) facilitate streamlined antibiotic regimens using bedside point-of-care (POC) tests (BinaxNOW pneumococcal and legionella urinary antigens, and nasopharyngeal swab for influenza PCR), reducing total amount of antibiotic prescribed both in route and spectrum.
Aims and objectives
Aim: To enhance the quality of care for adults admitted to hospital with community-acquired pneumonia.
- Implement the NICE pneumonia guidelines, leading to ≥70% concordance in year 1, and 80% in subsequent years.
- Identify patients with low severity CAP for outpatient management, implementing early telephone-supported discharge and follow-up, reducing their median LOS by 1 day;
- Streamline 1/3 antibiotic regimens using point-of-care microbiological tests within 48 hours of admission, reducing total amount of antibiotics prescribed both in route (oral over intravenous) and spectrum (narrow over broad);
The particular facets of the NICE pneumonia guidelines referred to in point 1 include:
- Chest radiograph and antibiotics within 4 hours of arrival to hospital
- Severity assessment using the CURB-65 tool
- Appropriate antibiotic therapy as defined by route, duration and selection.
- Safe, appropriate and supported discharge from hospital
- Patient education about expected symptom resolution both face-to-face and using written information
Reasons for implementing your project
Over 100,000 patients with Community Acquired Pneumonia (CAP) are admitted annually to UK hospitals; 18% of these patients die, and median LOS is 5 days. Outpatient management of low severity CAP is safe, and associated with high patient satisfaction, but in our local teaching hospital trust (catchment ~650,000 people), of ~35% patients with low severity CAP, ~90% remained in hospital.
The current estimated cost per excess bed-day for CAP is £228, based on HRG code DZ11A (taken from the NICE pneumonia guideline). As ~87% cost is bed occupancy, reducing LOS allows large savings consistent with the National QIPP agenda. Broad-spectrum antibiotics are associated with risks to individuals and wider public health. They cause Clostridium difficile diarrhoea, a priority for the Department of Health, antibiotic resistance, anaphylaxis and side effects.
Antibiotic over-prescription has been identified as a problem of national importance (as evidenced by recent statements on the issue by the Prime Minister and the subject of the 2014 Longitude Prize), and reducing unnecessary prescription will inevitably enhance patient safety. Point-of-care non-culture microbiological testing improves the diagnostic yield in CAP to around 50% from around 30%, potentially allowing antibiotic streamlining in these patients, and is cost effective. It allows earlier microbiological diagnosis than conventional culture tests, with results available in around 15 minutes. Crucially, rapid microbiological testing may reduce length of hospital stay.
Concordance with international guidelines improves care quality as defined by time from admission to achieve clinical stability, length of hospital stay, 30-day mortality, and resource use. The proportion of patients nationally whose care is concordant with BTS and NICE guidelines is 55-82%, and a recent audit of CAP at RDH showed that only half of CAP episodes locally are guideline concordant.
The problems with the current approach to CAP management are therefore threefold:
- NICE Guideline concordance (and care quality/outcome) was poor.
- Patients of low severity were managed in hospital rather than as an outpatient;
- Antibiotic stewardship (and the potential for streamlining regimens based on rapid microbiological testing, with earlier decision making and discharge) was limited.
How did you implement the project
Pneumonia was highlighted as an area for having high re-admissions through the reducing readmission Transformation Programme and in February 2016 a pilot respiratory infections team was introduced at RDH, comprising a pneumonia specialist nurse, with unfunded supervision from an antimicrobial pharmacist and respiratory consultant. Patients admitted with CAP are reviewed clinically within 18 hours of admission. However, due to the limits on nurse and consultant time, many patients admitted out of working hours were missed, and whilst the intervention was highly successful in those patients reviewed by the service, many were missed.
Following this successful pilot, a bid was entered for the NHS England East Midlands Area Team Marginal Rate Emergency Tariff (MRET) & Readmission Fund Investment for Specialised Services in January 2017. This was successful, and £252,000 was awarded to further expand the team.
The service was developed in conjunction with the Trust Transformation team, with access to peer review via the "Safer, Better, Faster" Trust quality improvement group. In addition, the company manufacturing the point-of-care microbiological tests (formally Alere, now Abbott) offered to fund them free of charge, providing that access was given to published data 1 month ahead of time. The team have at all times retained full control over published data and service design.
Once the additional specialist nursing staff were recruited, the service has able to operate between 8am and 8pm, every day of the year, since October 2017. We have also introduced the following services:
- Nurse-led outpatient clinics, allowing both face-to-face and virtual follow up of patients to ensure clinico-radiographic resolution.
- Recognition of associated predisposing factors including nutrition and sputum clearance or swallowing deficits, and early referral to the appropriate services.
- Educational role for the junior medical teams, to disseminate good practice.
- A weekly educational meeting free for anyone to attend, dealing with academic issues surrounding respiratory infection, talks from allied health professionals, and radiology interpretation sessions.
Over the first year the team reviewed 351 patients with suspected CAP; 50 had a chest radiograph reported as clear and were excluded, leaving 301 for analysis. Length of hospital stay (LOS) was reduced when compared with pre-intervention after adjustment for disease severity using CURB-65 (low severity, 2.8 vs 4.4 days, p<0.01; moderate severity, 4.3 vs 7.6 days, p<0.01; high severity, 6.0 vs 8.9 days, p=0.07).
Readmission rate at 30 days was unchanged (54/301, 17.9% vs 50/324, 15.4%, p=0.45). Early supported discharge was appropriate in 51/172 (30.0%) patients with low severity CAP; in this group median LOS was 1.4 days and readmission rate 6/51 (11.8%). A positive microbiological diagnosis was made in 69/301 (22.9%) patients compared with 16/324 (4.9%) pre-intervention; 60/301 (19.9%) had a positive POC test with a result available within the acute admitting area.
As a result, broad spectrum antibiotic regimens were streamlined in 43 (14.3%) patients. We are continuing to collect data on all of these parameters following the introduction of the full respiratory infections team. We are collecting qualitative data on patient and colleague experience both during the hospital admission and at follow up clinic, after the episode is complete, using an online survey.
To date, 100% patients were happy with the care received by the respiratory infections team. Comments included those below: "I was really, really pleased with the overall treatment I received from Vicky. Since returning home I have found the follow up phone calls invaluable; offering reassurance that I am sure aided my improvement as it reduced the stress of the ongoing symptoms. I am aware that the same advice was repeated to me several times (due to the fact that I kept repeating the same questions) but again I found this very, very helpful and reassuring. Thank you very much."
Clinician colleagues have found this novel service both challenging to their current practice, but also helpful from an educational perspective.
Key learning points
This is a novel project, and a respiratory infections service in this form is not provided to our knowledge in any other centre. Therefore, we have had to adapt in many ways during the design and implementation phases. All of the team members have had to change aspects of their involvement, with some examples below:
- Specialist nurses. They have had to be responsive to what works and what doesn't, and be open to change. There has been considerable clinical learning "on the job", as this role is new to all members of the team, unlike other roles such as COPD or asthma nursing. There have been times when the nurses have felt out of their depth, and we have overcome this be working very closely together as a team, and providing regular support from the senior management nursing and consultant team.
- Consultant and nursing leads. The leads have had to manage expectations of what can be achieved, and over what timescale. It has also been challenging to work with colleagues (who often think that they are experts at managing pneumonia) and encourage them to accept and trust help from a specialist nursing team.
Things that have worked:
- Engagement from the Trust transformation team from the outset has made turning a clinical idea into reality a much more viable prospect.
- Strong leadership from the senior medical and nursing team, with a clear idea of "what good looks like".
- A good partnership with the private sector (in this case, the company making the point-of-care test kits) has benefited both parties.
Things to avoid:
- Ensure that team expectations are managed appropriately, particularly from the clinical teams who are desperate for the team to be a success in challenging pressure of work situations.
- Ensure that a clear management and pastoral structure is clear from the outset.