Running head: PNEUMONIA GUIDELINES IN A RURAL HEALTH CARE SETTING
Pneumonia guidelines in a rural health care setting
Shannon Peterson, RN, BSN, Lindsay Iverson, DNP & Christopher Wichman, PhD
Creighton University
1
Comment [ILM1]: Refer to p. 41 of APA
manual- should be Pneumonia Guidelines in a Rural
Health Care Setting
PNEUMONIA GUIDELINES IN A RURAL HEALTH CARE SETTING
2
Abstract
Purpose: Quality indicators and mortality rates for acute myocardial infarction, congestive heart
failure, and pneumonia have been reviewed in studies with critical access hospitals (CAHs)
consistently having worse outcomes compared to urban and non-CAH systems. CAHs using
clinical decisions support systems (CDSS) have higher rates in Centers for Medicare and
Medicaid Services (CMS) indicators. Evaluation of patient outcomes in a rural setting is needed
Comment [ILM2]: Do you need this?
due to the lack rural health care information. The purpose of this quality improvement project is
Comment [ILM3]: I assume you mean rural
health care research?
to evaluate pneumonia patient outcomes in a 25 bed CAH in the rural Midwest.
Methods: Utilized a retrospective design of a convenience sample of all pneumonia patients
admitted one year before (n = 81) and one year after (n = 70) the May 2012 care map
implementation. Patient demographics, comorbidities, 30-day mortality, use of guidelines initial
antibiotic therapy (IAT), and length of stay (LOS) were analyzed using frequencies, Fisher’s
Comment [ILM4]:
exact test, and Wald’s Chi square as appropriate.
Findings: Anti-biotic therapy concordant with community acquired pneumonia (CAP) was
provided for 105 of the 150 patients, regardless of health care-associated pneumonia (HCAP) or
CAP categorization. In hospital mortality, rate of G-IAT and time to clinical stability outcomes
did not have a significant difference. Significant improvement achieved in 30-day mortality (P =
.0208), CDSS use (P = .0128), and length of stay (P = .0150) after implementation of evidence
based practice pneumonia care map
Conclusion: CAH systems provide essential, caring, and high quality service. Implementation
of pneumonia care map significantly improved patient outcomes.
Keywords: Rural healthcare, critical access hospital, pneumonia, outcomes, and guidelines.
Comment [ILM5]: Define this- since above you
define IAT, is this the same?
PNEUMONIA GUIDELINES IN A RURAL HEALTH CARE SETTING
3
Pneumonia guidelines in a rural health care setting
Comment [ILM6]: Pneumonia Guidelines in a
Rural Health Care Setting
In the 1890’s, pneumonia received the title of “Captain...of Death” by Sir William Osler
(Marrie, 1994). Mortality rates have greatly decreased since the 1930’s primarily due to
development of antibiotics and a vaccine against the most common pathogen in community
acquired pneumonia (CAP), Streptococcus pneumoniae (Hoyert, 2012). Mortality data from the
Centers for Disease Control lists pneumonia as the eighth leading cause of death in the United
States (Hoyert & Xiu, 2012). The costs of CAP and healthcare-associated pneumonia (HCAP)
care are substantial and increase with patient age, comorbidities and severity of pneumonia (Hsu,
Siroka, Smith, Holodniy, & Meduri, 2011; Menendez et al., 2012; Ott et al., 2012; Restrepo &
Frei, 2010; Sato, Rey, Nelson, & Pinsky, 2013).
Studies at urban and teaching health centers have shown that guideline adherent IAT for
CAP significantly lowers 30-day and in-hospital mortality, LOS, time to clinical stability
Comment [ILM7]: Even though it is spelled out
for the first time in you abstract, need to do it again
the first time you use abbreviation since the abstract
and paper are considered separate documents and
can be separated from each other
(TTCS), and time to switch to oral therapy (Frei et al., 2011; Grenier et al., 2011; Mandell et al.,
2007). Research on the implementation of pneumonia care maps has been completed in large
health systems with positive outcomes (Frei et al., 2006; Frei et al., 2011). Current research
available on outcomes in rural healthcare comes primarily from reviews of Centers of Medicare
and Medicaid (CMS) quality indicators comparing urban, rural, and CAH health system
performance (Joynt et al., 2011; Joynt, Orav, & Jha, 2013; Laditka, Laditka, & Probst, 2009;
Lutfiyya et al., 2007).
Rural areas are frequently excluded from primary research due to concerns of statistical
significance and confidentiality in a small population (Bellamy et al., 2011). The majority of
rural health systems are CAHs (Casey, Hung, McClellan, & Moscovice, 2013). Mortality rates
for myocardial infarction, congestive heart failure, and pneumonia patients are higher in CAHs
Comment [ILM8]: I have mixed feelings about
this sentence. It almost seems thrown in there, and I
feel wanting to know more information about CAHs
since you mention it several times. Could you
include a definition of CAH?
PNEUMONIA GUIDELINES IN A RURAL HEALTH CARE SETTING
4
compared to rural non-CAH facilities and urban hospitals (Joynt et al., 2011; Joynt, Orav, & Jha,
2013). Evaluation and monitoring of outcomes in a rural settings and CAH systems are needed
due to the lack of information specific to rural healthcare (Mitchell et al., 2013).
Comment [ILM9]: Good transition
Rural healthcare
Approximately 20% of the United States population or 60 million people live in rural
Comment [ILM10]: Insert commas around “or
60 million people”
areas (Bellamy, Nelson Bolin, & Gamm, 2011; Joynt et al., 2011; Laditka, Laditka, & Probst,
2009). In healthcare research and policy, rural is defined in 15 different ways, including by zip
code, county, and census geography blocks (Coburn et al., 2007). Rural-Urban Commuting Area
codes (RUCAs), the definition used by the Office of Rural Health Policy to determine eligibility
for programs, combines US Census data and Office of Management and Budget county
metropolitan status into one system (RAC cite again). A RUCA of 1 is considered the most
urban and heavily populated, with 9 being the most rural and with very low population density
(Reynnells & LaCaille John, 2013). The study system is located in a level 7 RUCA where less
than 25% of the population routinely commutes to urban areas for employment and the
population of the largest town does not exceed 9,999 (Rural Assistance Center [RAC], 2013).
The American Hospital Association (AHA) lists 5,724 hospitals in the United States.
Rural systems account for 1,984 systems with a significant majority (1,328) of these are CAHs
Comment [ILM11]: Is this definition used by
others in the journal? How did you decide to use this
definition? If you choose to include this definition,
then need to expand on the significance of using this
definition. How does a level 7 RUCA impact your
study? Do the numbers 1, 7 and 9 need to be written
out as per APA?
(Casey et al., 2013). CAH systems have a different payment structure from Medicare, are limited
to 25 beds and have less specialist and inpatient services than urban hospitals (RAC, 2014). The
CAH provides more to rural areas than inpatient care. Laboratory testing, physical therapy,
diabetic education, and visiting specialists are frequently based out of the CAH (Lipsky &
Glasser, 2011). Facilities also serve as community resources, providing space for walking during
inclement weather and opening public areas for community events such as prom pictures and
Comment [ILM12]: Okay, I see this now… I
think your definition of CAH should come earlier
PNEUMONIA GUIDELINES IN A RURAL HEALTH CARE SETTING
5
volunteer luncheons (Cass County Health System, 2013). CAH systems are frequently the
largest employer in the area they serve (Lipsky & Glasser, 2011).
According to the National Rural Health Association (NRHA) (2013), 10% of physicians
practice in rural areas. Providers in rural areas have the opportunity to be more connected with
the community and population allowing for more understanding of patient needs and personal
context (Chipp et al, 2013). The population these providers serve differ more urban areas. Rural
Comment [ILM13]: Sentence does not make
sense
residents are less likely to have adequate insurance or are uninsured, on average make less
money, and must travel more miles to reach emergency or primary care services. Unemployment
rates are higher and access to higher education is limited. All of these factors combined place
rural residents at higher risk for chronic disease, as well as complicate the ability of patient and
provider to appropriately manage comorbidities (Jukkala, Greenwood, Ladner, & Hopkins,
Comment [ILM14]: Good summary
2010).
Pneumonia
Pneumonia is the number one diagnosis seen in emergency departments and subsequently
admitted to CAH facilities of the three main CMS core measure reporting diagnoses (Casey,
McCullough, & Kreiger, 2014). Pneumonia is broken down into categories based on symptom
timing and likely infectious etiology: Community acquired pneumonia (CAP), healthcareassociated pneumonia (HCAP), Hospital acquired pneumonia (HAP), and ventilator-associated
pneumonia (VAP) (ATS/IDSA, 2005; Anand & Kollef, 2009; Mandell et al., 2007). Current
pneumonia guidelines were published in 2005 for HCAP, HAP, and VAP by a joint effort of the
American Thoracic Society (ATS) and Infectious Diseases Society of America (IDSA). CAP
guidelines were most recently updated in 2007 (Mandell et al., 2007). Updated guidelines for all
categories of pneumonia are expected in 2015(Infectious Disease Society of America, 2014).
Comment [ILM15]: Insert space between 2015
and parenthesis
PNEUMONIA GUIDELINES IN A RURAL HEALTH CARE SETTING
6
Anand and Kollef (2009) explain that the key difference between pneumonia types is the
onset of symptoms and time of admission to the hospital. Patients with pneumonia on admission
or within the first 48 hours of inpatient care are considered HCAP or CAP. Pneumonia that
develops after 48 hours is classified as HAP or VAP. The majority of studies regarding HAP
and VAP involved patients who are intubated and mechanically ventilated (ATS/IDSA, 2005).
This type of patient is not routinely managed in the CAH setting and is not evaluated in this
Comment [ILM16]: Was not?
project. The largest body of literature and area of current debate focuses on CAP and HCAP
guideline adherent therapy.
Guideline IAT for CAP consists of treatment with a respiratory fluoroquionolone alone or
dual therapy with both macrolide and beta-lactam therapy (Mandell et al., 2007). Due to the
wide possibility of pathogens in HCAP and risk of MDROS three different antibiotics are
Comment [ILM17]: Spell out
required for guideline HCAP IAT: An anti-pseudomonal cephalosporin or antipseudomonal
carbepenem or a β-lactamase inhibitor, with a flouroquinolone or aminoglycoside, and to cover
possible MRSA infection linezolid or vancomycin ( [ATS/IDSA], 2005). The current definition
Comment [ILM18]: Spell out
of HCAP has been contested in some circles as being too heterogeneous or all inclusive,
therefore causing broad spectrum antibiotics to be given where it is not needed (((Chalmers,
Comment [ILM19]: When it is not needed?
Rother, Salih, & Ewig, 2014; Grenier et al., 2011; Lopez, Amaro, & Polverino, 2012)(Shindo et
al., 2013)(Wunderink & Waterer, 2014,).
Comment [ILM20]: What exactly is going on
with this citation?
Pneumonia care and treatment, especially in the older population, can have many factors
play into the outcomes of the patient including comorbidities, quality of life, and ethical
considerations (Ewig, Welte, Chastre, & Torres, 2010, Faverio et al., 2014). El Solh et al. (2009)
compared outcomes of nursing pneumonia patients at three tertiary-care hospitals in New York
state. Using a retrospective design they classified patients as CAP or HCAP based on the
Comment [ILM21]: ?? Nursing? Do you mean
nursing home?
PNEUMONIA GUIDELINES IN A RURAL HEALTH CARE SETTING
7
antibiotic treatment received. In this review 77% of the 334 nursing home patients were treated
Comment [ILM22]: Insert comma after review
with HCAP therapy. There was no significant difference in time to clinical stability, in-hospital
or 30 day mortality in patients treated with CAP or HCAP therapy. The authors concluded that
factors outside of the providers’ control of antibiotic choice play significant roles in this
population of patients.
Comment [ILM23]: Insert reference citation
Improved patient outcomes for HCAP patients, when receiving CAP treatment has been
documented in a review of HCAP patient outcomes at the VA health center in Oklahoma by
Chen et al. (2013). CAP antibiotic therapy was received by 122 patients and HCAP antibiotic
Comment [ILM24]: Re word this sentence
therapy by 166 patients. The CAP therapy group had shorter duration of intravenous medication
(P <.0001), shorter hospital stay (P <.0001), lower rates of readmission in 30 days (P =.035), and
a significantly lower rate of secondary infections (P<.0001). Chen et al. (2013) concluded that
HCAP is currently defined too broadly and not all patients will benefit from increased
antimicrobial coverage.
Quality of care
Quality indicators are based off current research and reputable guidelines. Reporting of
quality measures, according to Chassin, Loeb, Schmaltz and Wachter (2010), began with Joint
Commission requirements and subsequently became part of CMS core measures. There were 16
core measures being reported in 2002; and increased to 31 in 2009. Starting in 2004, hospital
systems that did not report to CMS were penalized financially. CAH systems are not required to
report to CMS, although a large majority of systems participate on a voluntary basis (Casey,
Moscovice, Klinger, & Prasad, 2012). Mitchell et al. (2013), in their cross-sectional comparison
of pneumonia quality indicators, found that rural health systems that used clinical decision
support systems (CDSS) had higher rates of meeting CMS quality indicators. CDSS tools, which
Comment [ILM25]: Since this was something
you looked at for your study and you discuss it in
your manuscript, you need to define what you mean
by a CDSS
PNEUMONIA GUIDELINES IN A RURAL HEALTH CARE SETTING
8
are structured into electronic medical records and order entry were used in 18% of the CAH
facilities in the study.
Lutfiyya et al. (2007) found in their review of data from rural and urban hospitals, that
outcomes performance in pneumonia did not have significant differences. Urban centers did
perform better with AMI and heart failure outcomes. Joynt, Orav, and Jha (2013) recently
published a retrospective review of Medicare data from all fifty states covering 2002 to 2010.
More non-CAH facilities (68% vs 48%) improved their mortality rate over the time period
studied. CAH systems had a 1.8% higher (P<.001) mortality rate for all conditions compared to
non-CAH over the 8 years studied. Findings related specifically to pneumonia showed CAH
hospitals having a 1.7% higher (P<.001) mortality rate. Average 30-day mortality rates for
pneumonia in CAH systems ranged between 12.3% and 13.3%. Outcomes for pneumonia
patients in rural areas should be equivalent to those of urban health care centers when treated
with equivalent therapy. However equity of outcomes is not born out in the current literature,
making rural specific research and evaluation essential.
Purpose
A collaborative process involving the quality department, nursing managers, and system
providers was undertaken to update the pneumonia care map at one mid-western CAH system.
This system is the primary source of healthcare for the rural county in which it is located and is
listed in the top 100 CAH systems in the country (iVantage Health, 2013). A care map for
pneumonia has been in place since 1999 and had been updated semi-annually. The antibiotic
portion of the care map had been blank, requiring providers to write medication, dosage, and
timing parameters. A full page algorithm, on the back of the care map, was available to assist
providers in their antibiotic decisions. A new pneumonia order set with delineated formulary
Comment [ILM26]: I understand what you mean
in this transition, but the sentence does not really
make sense. What about “However, equity of
outcomes is not evidence in current review of the
literature….”
PNEUMONIA GUIDELINES IN A RURAL HEALTH CARE SETTING
9
antibiotics and clinical decision support questions for risks of HCAP, pseudomonas, and drug
resistant organisms based on current pneumonia guidelines was implemented in May of 2012.
This system change coincided with the conversion to all electronic order entry at the study
hospital. The aim of this project is to evaluate patient outcomes and the rate of guideline
Comment [ILM27]: Was to
adherent IAT before and after the May, 2012 implementation of an electronic pneumonia care
map in one CAH system. A secondary aim of the project is to identify any possible system or
Comment [ILM28]: Was to
population characteristics that may influence pneumonia outcomes.
Methods
The study is a retrospective design consisting of chart reviews of all pneumonia patients
admitted from the clinic or emergency department at the study hospital between May 1, 2011
through May 1, 2012 and from June 1, 2012 to June 1, 2013. The month of May 2012 was
excluded due to possible inconsistencies in care map usage during the adjustment to all
Comment [ILM29]: Can you make this more
clear? I think you need to reiterate that there was a
pre and a post group that were studied
electronic order entry. The study facility, located in the rural mid-west, is a CAH system with an
affiliated rural health clinic. Approval for this study was received by the Creighton University
Internal Review Board (IRB) as the study facility does not have an established IRB process.
Data collection took place between August of 2013 and November of the same year.
Inclusion and exclusion criteria
Initial inclusion criteria consisted of all patients age 18 or older, admitted to the study
hospital, and having a coded diagnosis of pneumonia. Any patient that developed symptoms of
pneumonia 48 hours after admission was excluded. Patients admitted for hospice or skilled care,
were pregnant, lacked radiological documentation of an infiltrate, required transfer to a tertiary
care hospital or intubation were also excluded.
Data collection
Comment [ILM30]: Move heading to go along
with text
PNEUMONIA GUIDELINES IN A RURAL HEALTH CARE SETTING
10
Patient data collected consisted of demographics, admission and discharge dates, medical
comorbidities, laboratory data, radiographic findings, blood and sputum culture results. Due to
the unique requirements of the CAH system, patients admitted observation and then changed to
acute status were treated as one hospital stay for the calculation of LOS. Primary outcomes
analyzed included guideline IAT, time to clinical stability, hospital LOS, provider use of CDSS,
in-hospital mortality and 30 day mortality.
CURB-65 (Chalmers et al., 2011) and HCAP risk scores (Shorr et al., 2012), were
collected to compare severity of illness in the study groups. The British Thoracic Society
proposed the CURB-65 criteria in 2003 (Chalmers et al., 2010). Confusion or mental status
changes, blood urea nitrogen value >7mmol/l, respiratory rate ≥30 per minute, blood pressure <
90mmHg systolic or ≤60mmHg diastolic, and age ≥65 are the five scoring criteria (Chalmers et
al., 2011). A score greater than or equal to two should be in the hospital, while score of three
and higher may need to be in the ICU (Lem et al., 2009).
Shorr et al. (2012) compared the results of their scoring tool, bacterial cultures, and
HCAP criteria groups. The average score of patients positive for resistant organisms was four.
A score of zero had a negative predictive value of multi-drug resistant organisms of 85%,
indicating that these patients were not likely to benefit from HCAP guideline antibiotic therapy.
Patient’s with a score of 6 or higher with the tool were very likely (P <.001) to have resistant
Comment [ILM31]: Write out six
organism infections. Final analysis comparisons showed the tool to have a 70.4% accuracy rate
compared to a 60.7% accuracy rate of the current HCAP definition ( [ATS/IDSA], 2005)for
identifying patients who would benefit from broad spectrum IAT.
Time to clinical stability (TTCS), as defined by Frei et al. (2006), is the first day a patient
has: heart rate ≤100, systolic blood pressure ≥90mm Hg, Respiratory rate ≤24 breaths per
Comment [ILM32]: Insert space
PNEUMONIA GUIDELINES IN A RURAL HEALTH CARE SETTING
11
minute, oxygen saturation ≥92% on room air, temperature ≤99 degrees, ability to tolerate oral
intake, and return to baseline mental status. TTCS is determined as the first date that a patient
meets all the criteria subtracted from date of admission. Due to the lack of a system wide scale
for documentation of patient mental status in the study hospital charting system, baseline mental
status was not used as part of the TTCS formula in this endeavor.
Statistical analysis
Statistical analysis was performed using SAS (SAS Institute, Inc., Cary, North Carolina).
Comparisons between the pre-implementation and post-implementation groups were performed
with through frequencies, Fisher’s exact test, and Wald chi-square as appropriate. Fisher’s exact
test was used to explore possible associations between various systems, comorbidities and
patient outcomes within the hospital and at 30 days post discharge from the hospital. Fisher’s
exact test was also used to compare the proportion of patients that died while in the hospital prior
to the implementation of the care map to the proportion of patients that died while in the hospital
after the care map implementation. The analysis was repeated for 30 day post discharge
mortality. Eight (8) patients died while in the hospital, and an additional four (4) failed to follow
up leaving a total of 139 patient outcomes for evaluation at 30 days post discharge.
Results
Population characteristics
Overall, 213 patients were admitted to observation or acute during the two periods, final
sample sizes were 81 and 70 patients in the pre and post-implementation groups respectively
(See Figure 1). The primary reason for exclusion consisted of no radiological findings of
pneumonia (68%), 15 patients were transferred to a tertiary care hospital, and seven developed
symptoms after being hospitalized for 48 hours. There were no significant differences identified
PNEUMONIA GUIDELINES IN A RURAL HEALTH CARE SETTING
12
between groups based on age, gender, ethnicity, comorbidities, or pneumonia type (See Table 1).
Scores based on the tool developed by Shorr et al (2012), were significantly higher in the preimplementation group (P = .0044). Average CURB-65 scores were also higher, but did not reach
significance.
Over 80% of the patients in the study were 65 or older, the youngest was 21 and the
oldest 106. The study population consisted primarily of Caucasian individuals with one Hispanic
Comment [ILM33]: Still shocking to me!
individual in the post-implementation group. Rate of comorbidities in the population were all
similar, except for diabetes, which was of higher frequency in the pre-implementation group
(35.8% vs 25.7%). The majority of patients had blood cultures collected (129 out of 151
patients), however only six in the pre and seven in the post group were positive for growth.
Sputum cultures were obtained more frequently in the pre-implementation group (38.2% 18.5%)
Comment [ILM34]: Missing “vs”
and had a higher rate of positive growth (25.8% vs 11.7%) of various organisms (see Table 2).
Patient Outcomes
Fifty-three percent of the patients met healthcare-associated pneumonia (HCAP) criteria.
Patients with HCAP were more like to be older (P < .0001), have poorer kidney function (P =
.0251) and longer length of stay (P < .001). One patient in the pre-implementation group
received guideline IAT HCAP therapy. Anti-biotic therapy concordant with CAP was provided
for 105 of the 151 patients, regardless of HCAP or CAP categorization. Oral anti-biotic therapy
was ordered for five patients in the study, two pre and three post. These patients were excluded
from guideline IAT analysis, as normally this type of therapy is provided on an outpatient basis.
A total of 2 patients received alternate IAT due to allergies and three due to provider concern
Comment [ILM35]: Two that were in the preimplementation group and three that were in the
post-implementation group
Comment [ILM36]: Two
about renal function. These cases were considered guideline IAT for analysis. Despite overall
improvement in the rate of CAP guideline IAT it was not statistically significant (P = 0.0607).
Comment [ILM37]: Insert comma after IAT
PNEUMONIA GUIDELINES IN A RURAL HEALTH CARE SETTING
13
In hospital mortality rates were similar between both groups. Information regarding 30day mortality was unavailable in four cases due to the patients not following up with a study
system provider. Analysis of 30-day mortality excluded those who died in hospital (8) or were
Comment [ILM38]: Not clear- could you put
instead “a provider within the study system”
lost to follow-up (4). After adjustment, thirty-day mortality rates decreased significantly from
Comment [ILM39]: n=8
Comment [ILM40]: n=4
16% for the pre-implementation group to 3.2% in the post-implementation group (P = .0208).
Two comorbidities and one systemic feature were found to be associated with patient mortality
within 30 days of discharge from the hospital: heart failure, dementia, and nursing home
residence, respectively. Significant improvement in CDSS use (P = 0.0128) occurred after order
set implementation (60.5% vs 80.0%). Time to clinical stability outcomes did not have a
significant difference between groups. The primary reason for this in both the pre and postimplementation groups was continued need for oxygen therapy either as a new issue or above
previous prescribed levels. Length of stay decreased significantly from an average of 4.39 days
to 3.53 days post-implementation (P = .0150).
Discussion
This retrospective evaluation of patient outcomes before and after the implementation of
a guideline based pneumonia care map emphasizes the ability of CAH systems to provide quality
patient care. Despite a more severe flu and pneumonia season in 2012 to 2013 as compared to
Comment [ILM41]: I love this line!
2011and 2012 (CDC, 2014), patient outcomes significantly improved post-implementation.
Comment [ILM42]: Expand on this- what is the
significance of this? I think it is important!
While guideline CAP guideline IAT did not increase significantly in this study, a higher
percentage in the post-implementation group (pre 70.5% vs post 83.6%) received this treatment.
Statistically significant positive change in patient outcomes were realized with only modest
increases in CAP guideline IAT (See Figure 2).
Comment [ILM43]: Could you use a better word
here?
PNEUMONIA GUIDELINES IN A RURAL HEALTH CARE SETTING
14
Over eighty percent of the population in this study are over age 65, with the average age
being 77, and thirty percent of patients residing in nursing homes. The maximum age in both
groups was 106 and 104 respectively. Several charts in this study did contain documentation of
family or patient requesting less intensive care, including requests to order fewer antibiotics, at
admission to the hospital. This study was not structured to take into account end of life care
decisions between provider, patient, and families. This decision could impact mortality rates in a
negative manner while also representing high quality and personalized patient care.
Comment [ILM44]: Good
Limitations
This study has several limitations. As this care map and subsequent evaluation took
place at only one CAH system, the results may not be generalizable to other rural or CAH
facilities. However, similar findings of decreased LOS and mortality have been shown at larger
urban hospitals with implementation of pneumonia care maps (Frei et al., 2006; Frei et al., 2011).
Comment [ILM45]: Great job comparing to the
literature
Patient data from the study system and affiliated clinics was the only source for 30-day mortality
data. This information was unavailable for 4 patients due to lack of follow-up with the study
system. Although the number lost to follow up is small, future studies would be more accurate if
mortality data is confirmed through state or federal sources. A higher, but not significant (P =
.0637), percentage of HCAP patients were in the pre-implementation group. Sample size of only
two years limits ability to make true analysis of HCAP and CAP burden in rural health. Impact
of G-IAT for HCAP could not be explored, as this treatment was prescribed for only one patient
during the study period.
Very few patients had a length of stay that was longer than three to five days, even
counting observation days before moving to acute. Unique aspects of CAH systems allow for
easy discharge to acute skilled status within the CAH hospital, many times without the patient
Comment [ILM46]: four
PNEUMONIA GUIDELINES IN A RURAL HEALTH CARE SETTING
15
being required to change rooms. Larger urban and non-CAH hospitals do not necessarily have
the flexibility to transfer patients to skilled when they meet criteria and frequently must wait
until there is bed availability in another facility. Readmission within thirty days is a patient
outcome that is now being tracked by CMS (Axon & Williams, 2011). This study did not
evaluate this outcome, and it should be included in future CAH research.
Comment [ILM47]: Another good point
Conclusion/Recommendation
CAH systems provide essential, caring, and high quality healthcare in a slightly different
paradigm than urban hospitals. This study presents the positive outcomes from one CAH system
which undertook an interdisciplinary process to better utilize national pneumonia guidelines and
improve patient care. The study system plans to continue quality improvement in pneumonia
care, incorporating new guidelines when available, and to again formally evaluate patient
outcomes adding readmission rates to the analysis. Further research into risk factors and scoring
systems to better identify drug resistant organisms is needed to allow appropriate stewardship of
antibiotic resources. Research that explores the ethical decision process between family, patient,
and provider and the impact on care decisions would add to understanding of pneumonia care.
Studies should be undertaken at two or three CAH systems concurrently to have greater depth of
information and generalizability of findings. Finally, reviews of CMS quality indicators will not
present an accurate overview of patient outcomes in rural areas until all CAH facilities are
reporting.
Comment [ILM48]: Wow- great sentence
PNEUMONIA GUIDELINES IN A RURAL HEALTH CARE SETTING
16
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NHAP, and VAP. Seminars in Respiratory and Critical Care Medicine, 30(1), 3-9.
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PNEUMONIA GUIDELINES IN A RURAL HEALTH CARE SETTING
Table 1
Comment [ILM49]: Can you change the
formatting of this table so that the word
“implementation” is on one line?
Table 1: BASELINE CHARACTERISTICS OF STUDY PATIENTS
Variable
23
Pre
Implementati
on
Post
Implementati
on
P -Value
Comment [ILM50]: Should not be in bold – and
should only have this on top:
Table 1
Baseline Characteristics of Study Patients
Age >65 (%)
Nursing Home Residence
(%)
Female (%)
85.1
80.0
-
35.8
31.4
-
53.1
48.6
-
Smoker (%)
14.8
11.4
-
CHF (%)
37.0
34.3
-
Cancer (%)
14.8
14.3
-
Dementia (%)
28.4
30.0
-
Diabetes (%)
35.8
25.7
P = .2273
COPD (%)
41.9
40.0
-
Pulmonary Fibrosis (%)
Chronic Kidney Disease
(%)
Liver Disease (%)
2.5
2.9
-
25.9
27.1
-
0
1.4
-
CAP (%)
39.5
55.7
P = .0633
HCAP (%)
60.5
44.3
P = .0637
Died in Hospital (%)
6.2
4.3
-
Alive at 30 days (%)
84.0
96.8
P = .0208
CURB-65 Average score
2.28
1.94
P = .0556
Shorr Average score
2.64
1.63
P = .0044
Look at page 129 in your APA manual for
formatting of a table and figure – I believe this is
similar to AMA requirements
Comment [ILM51]: Refer to APA manual on
page 129 about what a table should look like- I am
not sure what AMA requires, but most tables and
figures in APA and AMA are the same
PNEUMONIA GUIDELINES IN A RURAL HEALTH CARE SETTING
Comment [ILM52]: Again, look at table
requirements
Table 2
Table2:IDENTIFIEDPATHOGENSBYCULTURETYPE
Variable
BLOOD
S.epidermidis
S.agalactiae
Staphcoagulaseneg
Micrococcusspecies
Haemophilus
S.hominis
S.pneumoniae
MRSA
Nogrowth
Notcollected
SPUTUM
NormalRespFlora
NoGrowth
Notcollected
Poorspecimen
E.coli
E.faecalis
Enterobactercloacae
Haemophilus
MRSA
Non‐groupAβ‐hemolyticStrep
S.pneumoniae
Pseudomonas
Serratiamarcesens
Pre
Implementation
2
1
1
1
1
0
0
0
61
14
17
5
50
1
1
1
1
1
1
1
1
0
1
24
Post
Implementation
3
1
0
0
0
1
1
1
55
8
8
3
57
0
0
0
0
0
0
0
1
1
0
Do not need to have Table 2 listed twice
Title should be underneath and italicized
PNEUMONIA GUIDELINES IN A RURAL HEALTH CARE SETTING
Figure 1
25
Comment [ILM53]: Need a title for each figure
Comment [ILM54]: You do not talk about ICD9 code anywhere else in your manuscript but you list
it in the figure- need to change this or clarify for this
a note underneath your figure
PNEUMONIA GUIDELINES IN A RURAL HEALTH CARE SETTING
Figure 2
26
Comment [ILM55]: See comments on previous
figure
This figure is confusing to me- need to have a figure
legend with what your lines mean (see page 163 in
APA manual)
Most figures have a description underneath the
figure explaining any additional information the
reader needs to know