The North Zealand CAP Monitor: Designing a Monitoring System for Improving Care for Patients with Community Acquired Pneumonia

Contect
We describe how we developed a monitoring system for community acquired pneumonia (CAP) at North Zealand Regional hospital. We serve 310.000 inhabitants and annually around 3200 patients with CAP are admitted. As part of a program of clinical pathways for common conditions, a pathway for pneumonia was designed and implemented in 2010.
Problem
In spite of our clinical pathway for CAP we found delays in start of treatment, overuse of antibiotics and long length of stay (LOS). Mortality was nearly 20 %.
Assessment of problem and analysis of its causes
We established an audit group of two nurses and two senior doctors. Direct observations of the clinical processes revealed problems of coordination, complex disease trajectories that did not fit with the pneumonia pathway, unclear guidelines and variation in their interpretation.
Intervention
We designed a measurement system to monitor patients with CAP and effects of interventions to improve the quality of their care. Based on current literature we defined and tested a set of indicators and designed an audit form, a database and a dashboard for presenting the results.
Two nurses monthly audited randomly selected files of patients with CAP. We started with 34 audit variables. Through repeated cycles of testing, feedback and discussions, we reduced the number of indicators to 22 and time per audit from 20 to 10 minutes.
Strategy for change
To link the monitoring system with our patient pathway for CAP we established an improvement team of clinicians from the emergency department and inpatient units.
Measurement of improvement
Audit results are presented as a multidimensional dashboard of aggregated baseline data and run charts to monitor changes.
Microbiological tests were delayed, often performed after antibiotics were started. Patients received IV antibiotics longer than recommended. Nearly 80 percent of treatment plans were re-evaluated on day three, but only 30 percent shifted to PO. Overall compliance with standards was only around 50 percent and there was great variability of process times and of compliance with recommended steps of the pneumonia pathway.
Lessons learnt
Quality of care for CAP was worse than expected.
Defining and agreeing upon a set of indicators was difficult and time consuming but useful to improve our understanding of how care for CAP was in routine clinical practice.
Several indicators we initially considered necessary required too tedious data collection or were not useful. So, we could reduce the number of indicators by nearly a third.
Important steps from audit to quality dashboard were:
Defining and testing audit variables
Testing the audit form
Defining indicators based on the audit variables
Designing a database
Designing and testing a dashboard to present indicators in a balanced way
Messages for others
Auditing patients with a common disease as CAP is useful to identify areas for improvement for a large group of patients. The baseline audit can serve as a basis for a monitoring system. Feedback of audit data requires a systematic approach that should include consideration of how best to present and communicate data.