A quality improvement initiative to improve adherence to national guidelines for empiric management of community-acquired pneumonia in emergency departments.

OBJECTIVE: The objective of this study was to improve the concordance of community-acquired pneumonia management in Australian emergency departments with national guidelines through a quality improvement initiative promoting concordant antibiotic use and use of a pneumonia severity assessment tool, the pneumonia severity index (PSI). DESIGN: and INTERVENTIONS: Drug use evaluation, a quality improvement methodology involving data collection, evaluation, feedback and education, was undertaken. Educational interventions included academic detailing, group feedback presentations and prescribing prompts. SETTING AND PARTICIPANTS: Data were collected on 20 consecutive adult community-acquired pneumonia emergency department presentations by each hospital for each of three audits. MAIN OUTCOME MEASURES: Two process indicators measured the impact of the interventions: documented PSI use and concordance of antibiotic prescribing with guidelines. Comparisons were performed using a Chi-squared test. RESULTS: Thirty-seven hospitals, including public, private, rural and metropolitan institutions, participated. Twenty-six hospitals completed the full study (range: 462-518 patients), incorporating two intervention phases and subsequent follow-up audits. The baseline audit of community-acquired pneumonia management demonstrated that practice was varied and mostly discordant with guidelines. Documented PSI use subsequently improved from 30/518 (6%, 95% confidence interval [CI] 4-8) at baseline to 125/503 (25%, 95% CI 21-29; P < 0.0001) and 102/462 (22%, 95% CI 18-26; P < 0.0001) in audits two and three, respectively, while concordant antibiotic prescribing improved from 101/518 (20%, 95% CI 16-23) to 132/462 (30%, 95% CI 26-34; P < 0.0001) and 132/462 (29%, 95% CI 24-33; P < 0.001), respectively. CONCLUSIONS: Improved uptake of guideline recommendations for community-acquired pneumonia management in emergency departments was documented following a multi-faceted education intervention.

Pethidine in emergency departments: promoting evidence-based prescribing.

OBJECTIVE: To reduce pethidine prescribing in hospital emergency departments (EDs). DESIGN: Multi-centre drug use evaluation (DUE) process. SETTING AND PARTICIPANTS: Emergency departments in 23 public hospitals (22 in New South Wales, 1 in Victoria) from 1 September 2002 to 31 August 2003. Participating hospitals included seven principal referral hospitals, six major non-teaching hospitals and 10 district or community hospitals. Data for comparison were collected from 12 non-participating hospitals. INTERVENTIONS: Hospital coordinators at each participating hospital were provided with support to implement a range of prescribing interventions in their ED in each of three DUE cycles. Interventions included educational materials (guidelines, posters, prescribing reminders), audit and feedback, and small-group discussions. Three audits of pethidine prescribing were undertaken. Prescribing was compared with evidence-based guidelines and non-concordance identified. MAIN OUTCOME MEASURES: Number of dosage units of parenteral analgesics issued to the ED from each hospital's pharmacy department was recorded monthly and aggregated in 3-month periods. RESULTS: In the 12 months between the preintervention period and the equivalent post-intervention period, pethidine use decreased by 62% in project hospitals (4669 to 1793 units) and 56% in control hospitals (1476 to 648 units). Six months after project completion there was a significantly greater reduction from baseline in participating hospitals (71%; 4669 to 1348 units) compared with non-participating hospitals (64%; 1476 to 532 units; P < 0.001). There was a concurrent increase in use of both morphine and tramadol. CONCLUSION: There was a sustained reduction in pethidine use during the study period, which may indicate successful promotion of safer analgesic prescribing. It is not clear whether changes were a result of collaborative DUE methods or other factors.

A quality use of medicines program for continuity of care in therapeutics from hospital to community.

OBJECTIVE: To evaluate adherence to an agreed minimum dataset for patient medication information exchange between hospitals and general practitioners. DESIGN: Quasi pre-post design with a supplementary post-program comparison group; sequential descriptive surveys of patients following recent discharge from public hospitals; opinion questionnaire for key hospital informants; stakeholder forum to review data and Quality Use of Medicines (QUM) action plans between pre- and post-program surveys. PARTICIPANTS AND SETTING: GPs and hospitals from the South East Area Health Service, Sydney. During 2000-2001, 81/124 GPs (65%) returned 147 patient questionnaires in initial follow-up; 88/119 GPs (74%) returned 131 questionnaires in final follow-up; a supplementary group of 54/120 GPs (45%) returned 66 questionnaires; 32/45 (71%) of nominated key informants responded to the hospital survey. RESULTS: Direct notification of GPs by hospitals of their patient's admission was unchanged from the initial level of 22%. The proportion of GPs providing medication information to the hospital increased from 38% to 51% at Stage 2 (P < 0.05) and remained at 52% at Stage 3. The proportion of GPs receiving discharge summaries directly (initially 2%) increased to 26% at Stage 2 (P < 0.001) and remained at 27% at Stage 3. CONCLUSIONS: System change is slow to occur, but changes that are implemented are maintained. The stakeholder forum suggested that a specific person should be responsible for GP liaison.