Analysis of adherence to national nosocomial pneumonia treatment guidelines

Edward H Eiland III¹, Kurt A Wargo², Wayne Hamm³, Ali AM Hassoun^1,4

¹Huntsville Hospital, Huntsville, AL, USA; ²Auburn University Harrison School of Pharmacy, Auburn, AL, USA; ³Pfizer Inc; ⁴Alabama Infectious Disease Center, Huntsville, AL, USA

Background: Guidelines for the management of adults with hospital-acquired (HAP), ventilatorassociated (VAP), and healthcare-associated (HCAP) pneumonia were recently updated. These evidence-based guidelines emphasize early, appropriate antimicrobials, as well as, de-escalation of initial therapy based upon microbiologic cultures and clinical response of the patient, and to shorten duration of therapy to a minimum effective period.

Objective: To evaluate adherence to the nosocomial pneumonia guidelines before and after a multifaceted educational intervention in conjunction with the implementation of an adult pneumonia order set.

Methods: A three phase, retrospective, observational analysis was performed among patients with nosocomial pneumonia in a tertiary care facility. The phases consisted of an analysis of medical charts to identify empiric antimicrobial therapy for patients with nosocomial pneumonia; education of physicians on the guidelines; and repeat review of medical charts of patients with nosocomial pneumonia to observe for guideline adherence. An adult pneumonia order set was introduced to the medical staff prior to the initiation of the observational analysis and provided a modality for prescribers to be most compliant with the current recommendations for treating pneumonia. Order set utilization was tracked throughout the observational analysis to determine if various educational interventions increased compliance.

Results: Thirty-three patients were evaluated pre-education: 5 transferred, 16 discharged, and 12 died. Thirty-one patients were evaluated post-education: 6 transferred, 21 discharged, and 4 died. The combined sixty-seven patients received two hundred forty-eight orders for forty-four unique antimicrobial agents from five different services. Appropriateness of antimicrobial prescribing, designated by adherence to the clinical practice guidelines, did not improve following an educational intervention. However, the adult pneumonia order set was utilized in forty-eight percent of the post-education group while only being implemented in nine percent of the preeducation group. The prescribing of single or additional antimicrobials, while utilizing the adult pneumonia order set, commonly resulted in overall noncompliance with the consensus guidelines.

Conclusion: This analysis showed that educational efforts alone were not effective in improving the appropriateness of prescribing empiric antimicrobial therapy in accordance with the guidelines. Prescribing compliance with pre-printed orders, in addition to periodic interactive educational interventions, should be addressed when introducing and maintaining adherence to new clinical practice guidelines.

Keywords: nosocomial pneumonia, clinical practice guidelines, educational intervention, pneumonia order set