Patients With CAP Leave Hospital Sooner With 3-Step Approach

June 1, 2012 — A simple 3-step plan for treating patients with community-acquired pneumonia (CAP) was safe and dramatically reduced hospital length of stay (LOS) compared with usual care, while having no adverse effects on readmissions, mortality, or patient satisfaction, according to new research findings.

Jordi Carratalà, MD, from the Infectious Disease Service, Hospital Universitari de Bellvitge, in Barcelona, Spain, and colleagues described their findings in an article published online May 21 in the Archives of Internal Medicine.

In an invited commentary, Bradley A. Sharpe, MD, from the Department of Medicine, University of California, San Francisco, writes, "[I]magine if, for the cost of a single sheet of paper and the effort required to place it in the patient's medical chart, you could reduce length of stay by 2 days and save up to $4600 per patient yet have no impact on readmission rate, 30-day mortality, or patient satisfaction.... Amazingly, [these authors] describe such a high-yield, low-risk, low-cost intervention."

According to the researchers, length of hospital stay (LOS) is the most important component of the cost of CAP when patients are hospitalized; however, LOS varies widely, suggesting that "physicians do not use a uniform strategy to decide hospital discharge," the authors note.

"[S]witching from IV to oral therapy as soon as patients are clinically stable may help shorten LOS and reduce associated costs," they add.

The current study investigated the use of a 3-step critical pathway in managing patients with CAP to determine whether it would be as safe as, and more effective than, usual care in reducing the duration of IV antibiotic therapy and LOS in hospitalized patients with CAP.

The 3-steps of the critical pathway involved, first, the early mobilization of patients, followed by the use of objective criteria for switching to oral antibiotic therapy, and then the use of predefined criteria for deciding on hospital discharge. The details of the 3-step pathway were included in a printed checklist in the patients' chart. In comparison, "usual care" involved the standard practice of individual attending physicians.

A total of 401 adults who required hospitalization for CAP were randomly assigned to receive either the 3-step approach or usual care.

The median LOS was significantly shorter in the 3-step group than in the usual care group (3.9 days vs 6.0 days, respectively; P < .001). Likewise, the median duration of IV antibiotics use was shorter, at 2.0 days vs 4.0 days for the 2 groups, respectively (P < .001).

In addition, more patients assigned to usual care experienced adverse drug reactions (15.9% vs 4.5%; P < .001), whereas subsequent readmissions, case fatality rate, and patients' satisfaction with care were comparable between the groups.

"[I]n a population of immunocompetent adults with CAP requiring hospitalization, the use of a 3-step critical pathway was safe and effective in reducing the duration of IV antibiotic therapy and LOS and did not adversely affect patient outcomes," Dr. Carratalà and colleagues concluded.

Dr. Sharpe suggests that clinicians use this article to reflect on their practice. "Do you follow these simple evidence-based measures? Are your patients mobilized early? Do you review vital signs and consider a switch to oral antibiotics each day? Do you monitor mental status and oxygenation each day to evaluate for possible discharge?"

The study was not commercially funded. The authors and editorialist have disclosed no relevant financial relationships.

Arch Intern Med. Published online May 21, 2012. Article full text, Commentary full text