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Published on: August 30, 2018
Emergency department operational changes in response to pay-for-performance and antibiotic timing in pneumonia
Jesse M Pines1, Judd E Hollander, Hoi Lee
1Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA. pinesjes@uphs.upenn.edu
Background:
The percentage of adult patients admitted with pneumonia who receive antibiotics within four hours of hospital arrival is publicly reported as a quality and pay-for-performance measure by the Department of Health and Human Services and is called PN-5b.
Objectives:
To determine attitudes among physician leaders at emergency medicine training programs toward using PN-5b as a quality measure for pay for performance, and to determine what operational changes academic emergency departments (EDs) have made to ensure early antibiotic administration for patients with pneumonia.
Methods:
The authors administered an online questionnaire to 129 chairpersons and medical directors of 135 academic ED training programs in the United States on attitudes toward performance measurement in pneumonia and changes that academic EDs have made in response to PN-5b; one response was sought from each institution. Respondents were identified through the Society for Academic Emergency Medicine Web site and e-mailed five times to maximize survey participation.
Results:
Ninety chairpersons and medical directors (70%) completed the survey; 47% were medical directors, 51% were chairpersons, and 2% were medical directors and chairpersons. Forty-five (50%) did not agree that PN-5b was an accurate quality measure, and 61 (69%) did not agree that pay for performance targeting this measure would lead to improved pneumonia care. The most common strategy to address PN-5b was to provide information to providers on the importance of early treatment with antibiotics (n = 63; 70%). For patients with suspected pneumonia, 46 (51%) automate chest radiograph (CXR) ordering at triage, 37 (41%) prioritize patients with suspected pneumonia, and 33 (37%) administer antibiotics before obtaining CXR results. Overall ED changes include improved turnaround time for CXR (n = 33; 37%), prioritized CXRs over other radiographs (n = 13; 14%), and improved inpatient bed availability (n = 12; 13%). Of 13 strategies identified to improve PN-5b, the median number that programs have implemented is five (interquartile range, 5-7). All sites reported engaging in at least three operational changes to address PN-5b.
Conclusions:
All EDs in this study have addressed early antibiotic administration with multiple operational changes despite mixed sentiment that these changes will improve care. Future research is needed to measure the impact of pay-for-performance initiatives.
Insights
Physician leaders in academic emergency departments implemented operational changes for early pneumonia antibiotic administration, despite doubts about the quality measure PN-5b
Area of Science:
- Emergency Medicine
- Healthcare Quality Improvement
- Health Policy
Background:
- The Department of Health and Human Services uses PN-5b, a quality measure for early antibiotic administration in pneumonia patients, for public reporting and pay-for-performance.
- This measure assesses the percentage of adult pneumonia patients receiving antibiotics within four hours of hospital arrival.
Purpose of the Study:
- To assess attitudes of physician leaders in emergency medicine training programs towards PN-5b as a pay-for-performance quality measure.
- To identify operational changes implemented by academic emergency departments (EDs) to ensure timely antibiotic administration for pneumonia patients.
Main Methods:
- An online questionnaire was distributed to 135 academic ED training program chairpersons and medical directors in the US.
- Survey participation was maximized through five email invitations.
- Responses were collected from 90 (70%) program leaders regarding their views on PN-5b and implemented changes.
Main Results:
- 50% of respondents disagreed that PN-5b accurately measures quality, and 69% doubted its impact on improving pneumonia care.
- The primary strategy to address PN-5b was educating providers on the importance of early antibiotic treatment (70%).
- Operational changes included automating chest radiograph (CXR) ordering (51%), prioritizing pneumonia patients (41%), administering antibiotics before CXR results (37%), improving CXR turnaround time (37%), and prioritizing CXRs (14%).
Conclusions:
- Academic EDs have implemented multiple operational changes to improve early antibiotic administration for pneumonia.
- Despite these changes, there is mixed sentiment regarding their effectiveness in improving patient care.
- Further research is necessary to evaluate the impact of pay-for-performance initiatives like PN-5b.
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