Effect of increasing the intensity of implementing pneumonia guidelines: a randomized, controlled trial.
BACKGROUND
Despite the development of evidence-based pneumonia guidelines, limited data exist on the most effective means to implement guideline recommendations into clinical practice.


OBJECTIVE
To compare the effectiveness and safety of 3 guideline implementation strategies.


METHODS
Cluster-randomized, controlled trial.


METHODS
32 emergency departments in Pennsylvania and Connecticut.


METHODS
3219 patients with a clinical and radiographic diagnosis of pneumonia.


METHODS
The authors implemented a project-developed guideline for the initial site of treatment based on the Pneumonia Severity Index and performance of evidence-based processes of care at the emergency department level. Guideline implementation strategies were defined as low (n = 8), moderate (n = 12), and high intensity (n = 12).


METHODS
Effectiveness outcomes were the rate at which low-risk patients were treated on an outpatient basis and the performance of recommended processes of care. Safety outcomes included death, subsequent hospitalization for outpatients, and medical complications for inpatients.


RESULTS
More low-risk patients (n = 1901) were treated as outpatients in the moderate-intensity and high-intensity groups than in the low-intensity group (high-intensity group, 61.9%; moderate-intensity group, 61.0%; low-intensity group, 37.5%; P = 0.004). More outpatients (n = 1125) in the high-intensity group received all 4 recommended processes of care (high-intensity group, 60.9%; moderate-intensity group, 28.3%; low-intensity group, 25.3%; P < 0.001); more inpatients (n = 2076) in the high-intensity group received all 4 recommended processes of care (high-intensity group, 44.3%; moderate-intensity group, 30.1%; low-intensity group, 23.0%; P < 0.001). No statistically significant differences in safety outcomes were observed across interventions.


CONCLUSIONS
Twenty percent of eligible patients were not enrolled, and data on effectiveness outcomes were not collected before the trial.


CONCLUSIONS
Both moderate-intensity and high-intensity guideline implementation strategies safely increased the proportion of low-risk patients with pneumonia who were treated as outpatients. The high-intensity strategy was most effective for increasing the performance of the recommended processes of care for outpatients and inpatients.
Yealy
Donald M
DM
University of Pittsburgh and the Veterans Affairs Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania 15240, USA.
Auble
Thomas E
TE
Stone
Roslyn A
RA
Lave
Judith R
JR
Meehan
Thomas P
TP
Graff
Louis G
LG
Fine
Jonathan M
JM
Obrosky
D Scott
DS
Mor
Maria K
MK
Whittle
Jeff
J
Fine
Michael J
MJ
D000368:Aged; D017714:Community-Acquired Infections / Q000188:drug therapy; D003237:Connecticut; D004636:Emergency Service, Hospital / Q000592:standards*; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D010414:Pennsylvania; D011014:Pneumonia / Q000188:drug therapy*; D017410:Practice Guidelines as Topic; D011785:Quality Assurance, Health Care