1

Spreading best practice:

the ingredients for success

Pneumonia Mark Woodhead

Honorary Clinical Professor of Respiratory Medicine University of Manchester

Consultant in General & Respiratory medicine Manchester Royal Infirmary

Chair NICE Pneumonia GDG Chair DH Pneumonia working group

AQuA Pneumonia Clinical Lead

Diagnosis of Pneumonia

Symptoms of respiratory infection +

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ADMISSIONS TO NHS HOSPITALS IN ENGLAND ICD10 J10-18 INFLUENZA & PNEUMONIA

www.hesonline.org.uk

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

180,000

Age 0-14 Age 15-59 Age 60-74 Age 75+

1998-1999 1999-20002000-2001 2001-20022002-2003 2003-20042004-2005 2005-20062006-2007 2007-20082008-2009 2009-20102010-2011

Survived

Died

Survived

Died

Survived

Died

2011/2012

20.2%

2010/2011

20.4%

2009/2010

21.2%

In-hospital Mortality

n = 11,742 from BTS Audit

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In 2010

23,657 deaths

were attributed to

pneumonia in England

Pneumonia < 75 yrs: Admissions per 100,000 Population by PCT

Source DH personal communication

Range 91.4 – 231.4, Manchester 180.3

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Pneumonia Deaths Age <75 by PCT Rate/100,000

Range ~ 2.5 – 22.5

Manchester 3rd highest – 13.35

From

NHS Atlas of Variation

http://www.sepho.org.uk/extras/maps/NHSatlasRespiratory/atlas.html

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

910 1011 1112

Yes No No data

Antibiotics in line with local guidelines

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First hospital-based pay-for-

performance program in England

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All 24 NHS ‘acute’ hospitals in North west England

Population 6.8 million

28 Quality markers

Five conditions:

• pneumonia

• heart failure

• acute myocardial infarction

• coronary artery bypass grafting

• hip and knee replacement

1st year hospitals with quality scores in top quartile received bonus

of 4% of tariff for that condition.

Second quartile 2%

Next 6 / 12 “attainment” bonus if achievement in the second year

exceeded the median achievement level from the first year

“improvement” bonus if increase in achievement from the

first year was in the top quartile of increases in

achievement from the first year

“achievement” bonus if level of achievement in the

second year was in the top or second quartile of

achievement levels in the second year.

Thereafter withholding of payments via CQUIN system for poorest

performers

£3.2 million paid in first year, £1.6 million in next 6/12

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Hurdles:

Changing entrenched behaviours

Diverse admission pathways

Need to engage with a variety of clinical teams

Changes:

locations

staff

other guidelines/directives

Quality Improvement supported by:

data feedback

centralised support – standardised data collection

range of activities within hospitals

shared-learning events…….

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Managers

Coders

Information / data gatherers

Clinical audit

Clinicians

A & E

Medicine

AQ nurses

• oxygenation assessment within 24 hours of hospital arrival • Initial antibiotic consistent with current recommendations • Blood culture collected prior to first antibiotic administration • Receipt of first antibiotics within six hours of hospital arrival • Smoking cessation advice/counseling

• Composite score = sum of the above

Pneumonia Quality Indicators

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Initial Antibiotic Received Within 6 Hours of Arrival

30

40

50

60

70

80

90

100

1 2 3

%

Each point and line represents one Trust

Initial Antibiotic Received Within 6 Hours of Arrival

30

40

50

60

70

80

90

100

1 2 3

%

Each point and line represents one Trust

10

Composite Process Score

08/09 09/10 10/11

60

70

80

90

100

1 2 3

%

Each point and line represents one Trust

Sutton et al NEJM 2012;367:1821-1828

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Patient-level data from ALL 132 ‘acute’ hospitals in England

Plus 24 Trusts in NW England

Three conditions

• pneumonia (410,384)

• heart failure (201,003)

• acute myocardial infarction (245,187)

18 months before and 18 months after introduction

Pneumonia – Mortality Reduction Associated with AQ 1st 18 months

Sutton et al NEJM 2012;367:1821-1828

%

12

Pneumonia – Mortality Reduction Associated with AQ 1st 18 months

Sutton et al NEJM 2012;367:1821-1828

%

-2.5

-2

-1.5

-1

-0.5

0

North West Rest ofEngland

Otherconditions

Otherconditions

Pneumonia – Mortality Reduction Associated with AQ 1st 18 months

Sutton et al NEJM 2012;367:1821-1828

%

13

Pneumonia – Mortality Reduction Associated with AQ 1st 18 months

Sutton et al NEJM 2012;367:1821-1828

Equates to 890 fewer deaths

in the 18 month study period

The Future

Evolution /adaptation

changing hurdles

evidence – modification of quality indicators

National Care Bundle

BTS

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Chest x-ray. Accurate and early. Perform CXR within 4 h of admission in all patients with suspected CAP. Oxygen assessment. Assess oxygen saturations in all patients admitted with CAP. Severity assessment. Record severity of illness, supported by the CURB65 score, in all patients Bundle statement:. Treatment – timely & target. Administer timely (at least < 4 hours from presentation) and targeted antibiotics appropriate to severity of illness.

British Thoracic Society Care Bundle

The Future

Evolution /adaptation

changing hurdles

evidence – modification of quality indicators

National Care Bundle

BTS – current pilot in ~20 UK centres

National CQUIN