Pneumonia and the 4-Hour Antibiotic Rule in Hospital Care

Introduction: Pneumonia and the Case for Timely Antibiotics

The purpose of this project is to educate hospital staff on the fact that research supports a best practice protocol requiring pneumonia patients to receive antibiotics within four hours of being admitted to the hospital. Pneumonia is defined by Evans and Tippins (2007) as "an acute inflammation of the lower respiratory tract most commonly due to viral and bacterial infection. Areas or lobes of the lungs become consolidated, resulting in an impairment of gas exchange" (p. 224). The setting for this project is a tertiary hospital facility that provides surgical, medical, and rehabilitation services. The central question is whether pneumonia patients should receive antibiotics within a defined time frame — specifically, within four hours of hospital admission.

At present, pneumonia remains the leading cause of death attributable to infection in patients aged 65 years and older, and accounts for 13% to 48% of infections in the nursing home setting, with mortality rates as high as 55% (Solh, Akinnusi, & Alfarah et al., 2009). Community-acquired pneumonia (CAP) is a common condition that also carries a significant mortality rate. The management of a patient with CAP centers on assessment and correction of gas exchange and fluid balance, together with the administration of appropriate antibiotics (Finch & Woodhead, 1998).

The goal of this project is to improve compliance rates with hospital policies requiring antibiotic administration within four hours of admission. This goal is consistent with guidance from the Joint Commission and the Centers for Medicare and Medicaid Services (CMS), which stipulates that patients admitted with an initial diagnosis of pneumonia should receive an initial antibiotic dose within four hours of arrival (Four Hours to Start…, 2006). Nurses and physicians working in hospitals are required to apply the core measures implemented by hospital policy in order to meet standards of care and qualify the hospital for enhanced reimbursement under the Value-Based Purchasing directive initiated by CMS. Furthermore, these standards require 100% compliance and state that federal reimbursements will be tied to hospitals' performance levels (Four Hours to Start…, 2006).

Currently, approximately 1.2 million patients are hospitalized each year in the United States with pneumonia, and inpatient mortality rates average 5.8% (Lindenauer, Behal, & Murray et al., 2006). The economic consequences are substantial: pneumonia-related admissions cost more than $20 billion in direct healthcare costs annually (Lindenauer et al., 2006). Pneumococcal disease is presently the most prevalent form of community-acquired pneumonia in older adults, representing a significant clinical and economic burden, as well as exacerbating existing COPD conditions (Ludwig & Unal, 2012).

Opportunities to improve the care of patients with pneumonia have been well documented at both the state and national levels (Lindenauer et al., 2006). The timeliness of antibiotic administration and the selection of antibiotics remain suboptimal, despite the dissemination of national guidelines, resulting in higher morbidity for these patients (Lindenauer et al., 2006). Essential hospital-based prevention strategies include the establishment of clinical practice guidelines, the development of standard order sets and reminder systems, and the use of performance measurement and feedback — all of which improve care for this patient population (Lindenauer et al., 2006).

The results emerging from this project should therefore be of interest to all stakeholders, including hospital staff, physicians, nurses, patients, insurance companies, taxpayers, and government policymakers responsible for allocating Medicare funding. In sum, evidence demonstrates that administering antibiotics within four hours can prevent deaths in the Medicare population, offers cost savings for hospitals, and is feasible for most inpatients (Houck, Bratzler, Nsa, & Ma, 2007).

Dissemination Goals

The dissemination goals for this project are ultimately to reach all clinicians with the four-hour message in order to improve related patient outcomes. Beyond awareness, the goals also include changing practice and implementing a policy whereby hospital staff identifies early in the process those patients most likely to have pneumonia and implements "standing orders," "delegated orders," or "core measures" in response. These steps represent a predetermined set of treatment guidelines established on the basis of evidence-based research, dictating to hospital staff their responsibility to carry out antibiotic therapy within a time frame proven to improve outcomes for pneumonia patients admitted to the hospital.

The primary target audience consists of hospital staff — physicians and nurses — with the following priorities:

Target Audiences

Primary audience: Emergency room staff, including nursing staff and physicians on the hospital floors who receive direct admission patients, are the first to make contact with patients arriving at the hospital. This is where the clock begins, and pneumonia cases must be identified early.

Secondary audience: Bedside nurses who continue inpatient care after admission, as well as ancillary personnel such as nursing aides, the radiology department (who evaluate patients' lungs on X-ray), and the laboratory department (who collect blood culture specimens and perform other diagnostic workup tasks that contribute to identifying and managing pneumonia).