A Practice-Based Intervention toImprove Time-to-Antibiotic Administration in

Pneumonia Suspects atMulago Hospital, Kampala, Uganda

Luke Davis, MD

Pulmonary & Critical Care Medicine

June 3, 2008

Overview

• Background• Specific Aims• Preliminary Studies• Study Design• Assessment & Implementation Strategy• Measures• Analysis Plan• Human Subjects• Questions

Mulago Hospital, Ugandan Ministry of Health, Kampala

Mulago Hospital,

Kampala, Uganda

Outcomes of respiratory illness at Mulago Hospital are poor

• In-hospital mortality among TB suspects 13%

• Initial medical evaluation takes ~24 hours

• ~10% community acquired pneumonia (CAP) suspects

• Antibiotic treatment standardized, but not timing of administration

Antibiotic timing and CAP

• Early antibiotic administration a/w improved CAP outcomes1

• High-intensity education at time of implementation of CAP QI a/w increased adherence to guidelines2

• Systematic QI research uncommon in resource-limited settings and of unknown efficacy

1 Arch Intern Med 2004 Mar 22;164(6):637-44.

2 Ann Intern Med. 2005 Dec 20;143(12):881-94.

Specific Aims

To determine if a structured multimodal educational intervention can improve

1. Median time to antibiotic delivery

2. Hospital length of stay

3. Survival to discharge

In patients with pneumonia at Mulago Hospital

Research Methods

• Study population– Adults with cough and

pulmonary infiltrates

– Medical casualty ward, Mulago Hospital

• Study design– Prospective non-experimental

single-center cohort study

Preliminary Studies

• Epidemiology of pneumonia – 10% of all admissions, 1% or more CAP

• Focus groups– Interests of nurses and doctors misaligned– Pharmacists not integrated into health care team

Assessment strategy

• Project proposed by a senior registrar

• PRECEDE – PROCEED theory for assessing– Quality of life = mortality, length of stay– Epidemiology = median time to antibiotic delivery– Education = knowledge of guidelines– Administration = support of thought-leaders

Green & Kreuter, Health Program Planning, 4th ed., NY, London: McGraw-Hill, 2005.

Implementation strategy

1. Measurement– Baseline & serial quantitative & qualitative outcomes

2. Education– Disseminate guidelines based on local & international

literature, vetted by local thought leaders

3. Engagement of hospital leaders– Head of Medicine, Chief of Clinical Services, Hospital Director

4. Social marketing– Reminders and clinical decision support to doctors & nurses

5. Continuous Quality Improvement– Team of chief registrar, chief nurse, chief pharmacist

Control Intervention

Measures

• Outcomes – Time-to-antibiotic delivery, length of stay, hospital mortality – Measured q1month x 24 months

• Predictors and covariates– Intervention, time since implemented– Clinical and seasonal covariates– Time-to-antibiotic delivery, health-care worker qualitative ratings

• Measurement “semi-blinded”– Nurse records time of arrival– Pharmacist records time antibiotic released from pharmacy

Analysis Plan

• Interrupted time series regression

• Power calculated with month 1 data for each intervention

– Patients admitted with a respiratory complaint

– Effect size from Δ intervention coefficient

• Process evaluation through significant covariates– p<0.05 for interventions, time-to-antibiotic delivery– Important effect sizes of other covariates for generating hypotheses

Human Subjects

• Risk to patients low, potential benefit is high

• Participation of health care workers implies consent to process evaluation

• Data on knowledge, attitudes, and beliefs will be de-identified.

Questions