Effects of a pneumonia clinical pathway on time to antibiotic treatment, length of stay, and mortality

Objectives:A clinical pathway standardizing management for patients with an admission diagnosis of pneumonia was initiated after a previous study,foun d delayed time to initial antibiotic administration, a longer length of sta y, and higher mortality rate:for the authors' patients as compared with tho se in a "benchmark" hospital. The current study was undertaken to determine whether implementation of the clinical pathway resulted in statistically s ignificant decreases for these measures, both in the initial year following pathway implementation and two years later. Methods: A retrospective chart review was completed for three cohorts of pneumonia patients admitted via the ED: 1) three months immediately prior to pathway implementation, 2) 10- 12 months after implementation of the pathway, and 3) 34-36 months after im plementation of the pathway. Four standard antibiotic regimens were used fo llowing pathway implementation: community-acquired, community-acquired peni cillin-allergic, nursing home-acquired, and nursing home-acquired penicilli n-allergic. Demographics, medical history, presentation signs and symptoms, process of care, and outcome data,were abstracted from each patient's medi cal record. Results: The mean time to antibiotic administration decreased f rom 315 minutes prepathway to approximately 175 minutes during the first po stpathway period and 171 minutes at three years (ANOVA, p < 0.0001). The pe rcentage of patients who received antibiotics in the ED increased from 58% prepathway to 94% during the first postpathway period and 97% at three year s (chi square, p < 0.0001). Length of stay decreased from 9.7 prepathway to 8.9 days during the first postpathway period and 6.4 days at three years ( ANOVA, p < 0.0001). There was no significant change of in-hospital mortalit y (9.6% prepathway to 5.2% and 4.9%) in the two respective periods. Conclus ions: This study demonstrates that implementation of a pneumonia clinical p athway for the management of hospitalized patients admitted via the ED decr eases the time to initial antibiotic treatment and increases the proportion of patients initially treated with antibiotics in the ED. These effects we re evident in the first year following pathway implementation and sustained at the three-year study interval.