Impact of a Clinical Pathway for Hospital Management of Community-Acquired Pneumonia: A Retrospective Cohort Study

Jose Lorca Barchu00edn; Philip Erick Wikman-Jorgensen*; Lau00edz Bello; Reyes Pascual

**Jose Lorca Barchu00edn, Philip Erick Wikman-Jorgensen*, Lau00edz Bello and Reyes Pascual**

Volume2-Issue6
Dates: Received: 2021-06-18 | Accepted: 2021-06-03 | Published: 2021-06-04
Pages: 450-459

Abstract

Introduction: Community-acquired pneumonia is a prevalent disease that is managed in heterogeneous ways. Clinical pathways have been proposed as one way to mitigate this variability, but few implementation experiences have been published. The primary objective of this study is to analyse the effects of implementing a standardised clinical pathway for community-acquired pneumonia on length of hospital stay.

Methods: Retrospective cohort study comparing two equivalent time periods with and without a clinical pathway. We described patient characteristics in both periods and compared mean length of hospital stay, mortality, rate of complications, and readmissions within 30 days.

Results: A total of 170 patients were included across both periods. Mean length of hospital stay in patients treated before implementation of the clinical pathway was 6.05 days versus 5.43 days afterward (p = 0.28). The segmented regression analysis showed a change in slope for the length of hospital stay (0.04) following implementation of the clinical pathway. The proportion of patients hospitalised for more than 6 days was 37.5% in the first period, compared to 29.6% in the second (p = 0.088). Multivariable analysis showed that nonadherence to the clinical pathway was associated with a hospital stay of longer than 6 days (p = 0.048). Mortality dropped from 10.5% to 4.7% after the clinical pathway was established (p = 0.12). The proportion of patients readmitted within 30 days due to CAP was 8.8% before the establishment of the clinical pathway and 0% afterwards (p = 0.006).

Conclusion: A clinical pathway for managing community-acquired pneumonia was associated with a reduction in length of hospital stay and readmittance. There was a trend towards mortality reduction.

FullText HTML FullText PDF DOI: 10.37871/jbres1259

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How to cite this article

Barchín JL, Wikman-Jorgensen PE, Bello L, Pascual R. Impact of a Clinical Pathway for Hospital Management of Community-Acquired Pneumonia: A Retrospective Cohort Study. J Biomed Res Environ Sci. 2021 June 04; 2(6): 450-459. doi: 10.37871/jbres1259, Article ID: jbres1259

Subject area(s)

Clinical Trials

Public Health

Pulmonology

References

Montull B, Menéndez R, Torres A, Méndez R. Predictors of severe sepsis among patients hospitalized for community-acquired pneumonia. MLO Med Lab Obs. 2016 Mar;48(3):8, 10-2; quiz 14. PMID: 27116802.
Welte T, Torres A, Nathwani D. Clinical and economic burden of community-acquired pneumonia among adults in Europe. Thorax. 2012 Jan;67(1):71-9. doi: 10.1136/thx.2009.129502. Epub 2010 Aug 20. PMID: 20729232.
Rello J. Demographics, guidelines, and clinical experience in severe community-acquired pneumonia. Crit Care. 2008;12 Suppl 6(Suppl 6):S2. doi: 10.1186/cc7025. PMID: 19105795; PMCID: PMC2607112.
Welte T, Köhnlein T. Global and local epidemiology of community-acquired pneumonia: the experience of the CAPNETZ Network. Semin Respir Crit Care Med. 2009 Apr;30(2):127-35. doi: 10.1055/s-0029-1202941. Epub 2009 Mar 18. PMID: 19296412.
Vila-Corcoles A, Ochoa-Gondar O, Rodriguez-Blanco T, Raga-Luria X, Gomez-Bertomeu F; EPIVAC Study Group. Epidemiology of community-acquired pneumonia in older adults: a population-based study. Respir Med. 2009 Feb;103(2):309-16. doi: 10.1016/j.rmed.2008.08.006. Epub 2008 Sep 18. PMID: 18804355.
Ochoa-Gondar O, Vila-Córcoles A, de Diego C, Arija V, Maxenchs M, Grive M, Martin E, Pinyol JL; EVAN-65 Study Group. The burden of community-acquired pneumonia in the elderly: the Spanish EVAN-65 study. BMC Public Health. 2008 Jun 27;8:222. doi: 10.1186/1471-2458-8-222. PMID: 18582392; PMCID: PMC2522374.
Monge V, San-Martín VM, González A. The burden of community-acquired pneumonia in Spain. Eur J Public Health. 2001 Dec;11(4):362-4. doi: 10.1093/eurpub/11.4.362. PMID: 11766474.
Ewig S, Ruiz M, Torres A, Marco F, Martinez JA, Sanchez M, Mensa J. Pneumonia acquired in the community through drug-resistant Streptococcus pneumoniae. Am J Respir Crit Care Med. 1999 Jun;159(6):1835-42. doi: 10.1164/ajrccm.159.6.9808049. PMID: 10351928.
Rello J, Quintana E, Ausina V, Net A, Prats G. A three-year study of severe community-acquired pneumonia with emphasis on outcome. Chest. 1993 Jan;103(1):232-5. doi: 10.1378/chest.103.1.232. PMID: 8417885.
Bartolomé M, Almirall J, Morera J, Pera G, Ortún V, Bassa J, Bolíbar I, Balanzó X, Verdaguer A; Maresme Community-Acquired Pneumonia Study Group (GEMPAC). A population-based study of the costs of care for community-acquired pneumonia. Eur Respir J. 2004 Apr;23(4):610-6. doi: 10.1183/09031936.04.00076704. PMID: 15083763.
Fernández Alvarez R, Gullón Blanco JA, Rubinos Cuadrado G, Jiménez Sosa A, Hernández García C, Medina Gonzálvez A, González Martín I. Neumonía adquirida en la comunidad: influencia de la duración de la antibioterapia intravenosa en la estancia hospitalaria y relación coste/efectividad [Community-acquired pneumonia: influence of the duration of intravenous antibiotic therapy on hospital stay and the cost-benefit ratio]. Arch Bronconeumol. 2001 Oct;37(9):366-70. Spanish. doi: 10.1016/s0300-2896(01)78816-3. PMID: 11674935.
González-Moraleja J, Sesma P, González C, López ME, García JF, Alvarez-Sala JL. Cuál es el coste de las neumonías que ingresamos inadecuadamente? [What is the cost of inappropriate admission of pneumonia patients?]. Arch Bronconeumol. 1999 Jul-Aug;35(7):312-6. Spanish. doi: 10.1016/s0300-2896(15)30067-3. PMID: 10439127.
Antunes C, Pereira M, Rodrigues L, Organista D, Cysneiros A, Paula F, Nunes B, Barbosa P, Bárbara C, Escoval A, Diniz A, Froes F. Hospitalization direct cost of adults with community-acquired pneumonia in Portugal from 2000 to 2009. Pulmonology. 2020 Sep-Oct;26(5):264-267. doi: 10.1016/j.pulmoe.2020.02.013. Epub 2020 May 29. PMID: 32482604.
Julián-Jiménez A, González-Castillo J, Candel González FJ. ¿Cuándo, dónde y cómo ingresar al paciente con neumonía adquirida en la comunidad? Rev Clínica Española. 2013;213(2):99-107. doi:10.1016/j.rce.2012.02.006
Julián-Jiménez A, Timón-Zapata J, Laserna-Mendieta EJ, Pineda-Tenor D. El uso rutinario del Pneumonia Severity Index junto a otros criterios mejora el manejo de la neumonía adquirida en la comunidad en el servicio de urgencias [The routine use of the Pneumonia Severity Index together with other criteria improves the management of community acquired pneumonia]. Enferm Infecc Microbiol Clin. 2013 Mar;31(3):195-6. Spanish. doi: 10.1016/j.eimc.2012.09.006. Epub 2012 Oct 16. PMID: 23084605.
Muñoz LÁS, Cabeza MÁT, Herrero JC, et al. Desarrollo y proceso de mejora de la vía clínica ‘neumonía adquirida en la comunidad con ingreso hospitalario’ en un hospital de ámbito comarcal. Rev Calid Asist. 2006;21(6):299-310. doi: 10.1016/S1134-282X(06)70799-0
Capelastegui A, España PP, Quintana JM, Gorordo I, Gallardo MS, Idoiaga I, Bilbao A. Management of community-acquired pneumonia and secular trends at different hospitals. Respir Med. 2005 Mar;99(3):268-78. doi: 10.1016/j.rmed.2004.08.010. PMID: 15733501.
Frei CR, Bell AM, Traugott KA, Jaso TC, Daniels KR, Mortensen EM, Restrepo MI, Oramasionwu CU, Ruiz AD, Mylchreest WR, Sikirica V, Raut MR, Fisher A, Schein JR. A clinical pathway for community-acquired pneumonia: an observational cohort study. BMC Infect Dis. 2011 Jul 6;11:188. doi: 10.1186/1471-2334-11-188. PMID: 21733161; PMCID: PMC3142517.
Meehan TP, Weingarten SR, Holmboe ES, Mathur D, Wang Y, Petrillo MK, Tu GS, Fine JM. A statewide initiative to improve the care of hospitalized pneumonia patients: The Connecticut Pneumonia Pathway Project. Am J Med. 2001 Aug 15;111(3):203-10. doi: 10.1016/s0002-9343(01)00803-8. PMID: 11530031.
Marrie TJ, Lau CY, Wheeler SL, Wong CJ, Vandervoort MK, Feagan BG. A controlled trial of a critical pathway for treatment of community-acquired pneumonia. CAPITAL Study Investigators. Community-Acquired Pneumonia Intervention Trial Assessing Levofloxacin. JAMA. 2000 Feb 9;283(6):749-55. doi: 10.1001/jama.283.6.749. PMID: 10683053.
R Core Team. R: A language and environment for statistical computing. 2019.
Palomo López P, Redondo Mena C. Legislación vigente y Ética en Investigación Clínica. Rev Int Ciencias Podol. 2012;6(2):81-93. doi: 10.5209/rev_ricp.2012.v6.n2.39317
Ley 14/2007, de 3 de julio, de Investigación Biomédica (BOE, 4 de julio de 2007) [Law 14/2007, 3 July, on biomedical research (BOE, 4 July 2007)]. Rev Derecho Genoma Hum. 2007 Jan-Jun;(26):283-325. Spanish. PMID: 18201045.
Chen LP, Chen JH, Chen Y, Wu C, Yang XH. Efficacy and safety of glucocorticoids in the treatment of community-acquired pneumonia: A meta-analysis of randomized controlled trials. World J Emerg Med. 2015;6(3):172-8. doi: 10.5847/wjem.j.1920-8642.2015.03.002. PMID: 26401176; PMCID: PMC4566005.
Briel M, Spoorenberg SMC, Snijders D, Torres A, Fernandez-Serrano S, Meduri GU, Gabarrús A, Blum CA, Confalonieri M, Kasenda B, Siemieniuk RAC, Boersma W, Bos WJW, Christ-Crain M; Ovidius Study Group; Capisce Study Group; STEP Study Group. Corticosteroids in Patients Hospitalized With Community-Acquired Pneumonia: Systematic Review and Individual Patient Data Metaanalysis. Clin Infect Dis. 2018 Jan 18;66(3):346-354. doi: 10.1093/cid/cix801. PMID: 29020323.
Metlay JP, Waterer GW, Long AC, et al. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019;200(7):e45-e67. doi:10.1164/rccm.201908-1581ST
Pliakos EE, Andreatos N, Tansarli GS, Ziakas PD, Mylonakis E. The Cost-Effectiveness of Corticosteroids for the Treatment of Community-Acquired Pneumonia. Chest. 2019;155(4):787-794. doi:10.1016/j.chest.2018.11.001
Carratalà J, Garcia-Vidal C, Ortega L, et al. Effect of a 3-step critical pathway to reduce duration of intravenous antibiotic therapy and length of stay in community-acquired pneumonia: A randomized controlled trial. Arch Intern Med. 2012;172(12):922-928. doi:10.1001/archinternmed.2012.1690
Lloyd M, Karahalios A, Janus E, Skinner EH, Haines T, De Silva A, Lowe S, Shackell M, Ko S, Desmond L, Karunajeewa H; Improving Evidence-Based Treatment Gaps and Outcomes in Community-Acquired Pneumonia (IMPROVE-GAP) Implementation Team at Western Health. Effectiveness of a Bundled Intervention Including Adjunctive Corticosteroids on Outcomes of Hospitalized Patients With Community-Acquired Pneumonia: A Stepped-Wedge Randomized Clinical Trial. JAMA Intern Med. 2019 Aug 1;179(8):1052-1060. doi: 10.1001/jamainternmed.2019.1438. PMID: 31282921; PMCID: PMC6618815.
Prina E, Ranzani OT, Torres A. Community-acquired pneumonia. Lancet. 2015 Sep 12;386(9998):1097-108. doi: 10.1016/S0140-6736(15)60733-4. Epub 2015 Aug 12. PMID: 26277247; PMCID: PMC7173092.
National Institute for Health and Care Excellence. Pneumonia in adults : diagnosis and management. December, 2014. https://bit.ly/3fHafHz
Lim WS, van der Eerden MM, Laing R, Boersma WG, Karalus N, Town GI, Lewis SA, Macfarlane JT. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax. 2003 May;58(5):377-82. doi: 10.1136/thorax.58.5.377. PMID: 12728155; PMCID: PMC1746657.
Lee JS, Giesler DL, Gellad WF, Fine MJ. Antibiotic Therapy for Adults Hospitalized With Community-Acquired Pneumonia: A Systematic Review. JAMA. 2016 Feb 9;315(6):593-602. doi: 10.1001/jama.2016.0115. PMID: 26864413. Lee JS, Giesler DL, Gellad WF, Fine MJ. Antibiotic Therapy for Adults Hospitalized With Community-Acquired Pneumonia: A Systematic Review. JAMA. 2016 Feb 9;315(6):593-602. doi: 10.1001/jama.2016.0115. PMID: 26864413.
Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM Jr, Musher DM, Niederman MS, Torres A, Whitney CG; Infectious Diseases Society of America; American Thoracic Society. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007 Mar 1;44 Suppl 2(Suppl 2):S27-72. doi: 10.1086/511159. PMID: 17278083; PMCID: PMC7107997.
Horita N, Otsuka T, Haranaga S, Namkoong H, Miki M, Miyashita N, Higa F, Takahashi H, Yoshida M, Kohno S, Kaneko T. Adjunctive Systemic Corticosteroids for Hospitalized Community-Acquired Pneumonia: Systematic Review and Meta-Analysis 2015 Update. Sci Rep. 2015 Sep 16;5:14061. doi: 10.1038/srep14061. PMID: 26374694; PMCID: PMC4571641.