To measure quality-of-care variables relevant to the treatment of community-acquired pneumonia and to determine their relative contribution to variation in length of hospital stay (LOS).
One hundred cases of pneumonia requiring hospitalization from each of 7 institutions (2 community and 5 university teaching hospitals) were randomly selected (total sample, 700 cases). Demographic and clinical variables were abstracted using a standardized data instrument. Three quality-of-care measures were analyzed: (1) site of initial antibiotic treatment (emergency department vs floor), (2) door-to-needle time, and (3) appropriateness of antibiotic selection. Appropriate antibiotic selection was defined by the 1998 Infectious Disease Society of America guidelines for the treatment of hospitalized pneumonia cases. Regression modeling was used to determine associations between LOS and our quality-of-care (process) variables.
The mean ± SD LOS for this sample was 7.0 ± 4.1 days. Prolonged LOS, defined as greater than or equal to the 75th percentile of the LOS distribution, was the dependent variable in our regression analysis and was greater than or equal to 9.0 days. After clinical and demographic variables were adjusted for, logistic regression modeling revealed that all 3 quality-of-care measures were associated with prolonged LOS: (1) initial antibiotic treatment in the emergency department (odds ratio [OR], 0.31; 95% confidence interval [CI], 0.19-0.48); (2) appropriate antibiotic selection (OR, 0.55; 95% CI, 0.35-0.88); and (3) door-to-needle time (OR, 1.75 per 8 hours; 95% CI, 1.34-2.29). In a secondary analysis, we examined the clinical and demographic characteristics of the patients who were treated more rapidly in the emergency department compared with those who were treated on the inpatient floor. No clinically meaningful differences were observed between these groups.
Unlike clinical and demographic variables, process-of-care variables are modifiable and amenable to quality improvement. We observed that rapid antibiotic initiation and appropriate antibiotic selection in the emergency department have a statistically significant association with shorter LOS. These findings suggest quality improvement targeted at these processes of care may improve resource utilization and reduce LOS for patients with community-acquired pneumonia.