In the Veterans Health Administration there were over 21,000 hospitalizations for pneumonia in fiscal year 2008, pneumonia is the third leading medical discharge diagnosis, and is responsible for up to 4.5% of all inpatient discharges. In addition, pneumonia was responsible for 194,764 beds days (1.3% of total), which was similar to congestive heart failure (1.5%) and chronic obstructive pulmonary disease (1.8%), and higher than coronary artery disease, respiratory neoplasms, or depression. In 2006, length of hospital stay was considerably higher in the VA (7.8 days vs. 5.4) versus other non-federal hospitals. Not only does increased length of stay consume more VA resources, each additional hospital day puts patients at additional risk of an adverse event such as a falls or hospital-acquired infections. Major causes of this increased length of stay are delayed conversion from IV to oral therapy upon reaching clinical stability, and not discharging on the same day as the conversion to oral antibiotics. Therefore additional interventions are needed to decrease the length of stay for veterans hospitalized with pneumonia.
1) Develop and perform a local pilot implementation of an inpatient clinical reminder within Computerized Patient Record System to identify when patients hospitalized with pneumonia are clinically stable and ready for conversion form IV to oral antibiotic therapy and hospital discharge. 2) Test measures of the constructs of Theory of Reasoned Action and the Theory of Planned Behavior in VA medicine ward physicians and determine if they correlate with intention and discharge behavior. 3) Establish a collaborative of VA Medical Centers for the purpose of developing a larger scale implementation study to use evidence-based criteria to reduce LOS for patients hospitalized with pneumonia. 4) Prepare a VA HSR&D grant proposal for a cluster randomized controlled trial of a clinical reminder intervention to reduce length of hospital stay among veterans hospitalized with pneumonia
We developed and implemented a computer-based inpatient clinical reminder to assist physicians with appropriate conversion from IV to oral antibiotics and that encouraged discharge on the same day unless there were other social problems or unstable comorbid conditions. In addition, we secured support from key personnel and provided twice monthly provider education. We examined length of hospital stay for veterans with pneumonia 2 months after implementation and for those same months in the year prior. In addition, we used surveys to examine physician attitudes and potential barriers/facilitators to the introduction of inpatient clinical reminders. We are currently in the process of planning a larger, more definitive multi-center trial for this inpatient clinical reminder.
The inpatient clinical reminder was developed, piloted, and revised prior to implementation at a single VA medical center in March 2011. Educational and promotional activities started in February 2011. In April/May 2010 (pre-implementation) length of hospital stay was 7.3 days and in April/Mary 2011 (post-implementation) was 5.4 days (p= 0.05). Post-implementation surveys (n=27) demonstrated that although many providers believed that the clinical reminder would increase monitoring of clinical decisions (mean 5.3 on 1-7 scale) that the reminder provided helpful guidance (5.0) and that they wanted to use the reminder regularly (4.9).
The implementation of this project was associated with decreased length of stay for veterans hospitalized with pneumonia at a single VA medical center. Appropriately reducing length of hospital stay for pneumonia has been previously demonstrated to be associated with decreased costs and may potentially be associated with improved patient safety.
- Mortensen EM, Bollinger M, Fine MJ. Electronic medical record based intervention to reduce length of stay for Veterans hospitalized with pneumonia. Poster session presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 9; Philadelphia, PA.