title: Assessing processes of care to promote timely initiation of antibiotic therapy for emergency department patients hospitalized for pneumonia.
abstract: BACKGROUND
  A mixed-methods quality improvement (QI) project for patients with pneumonia hospitalized from the emergency department (ED) was undertaken to (1) delineate the basic steps in the flow of patient care from presentation in the ED to time to first antibiotic dose (TFAD), (2) identify perceived barriers to and facilitators of reduced TFAD within these steps, (3) describe QI strategies to improve TFAD rates, and (4) identify perceived strategies for facilities to enhance performance.
  
  
  METHODS
  The QI project was conducted at 10 lower- and 10 higher-performing Veterans Affairs hospitals on the basis of the proportion of patients whose TFAD was within four hours of presentation. An ED physician, an ED nurse, a radiologist, a pharmacist, and a quality manager from each site were invited to participate in a survey and focus group.
  
  
  RESULTS
  Of the 82 survey participants, 59 (72%) perceived that ordering and performing the chest radiograph was the step most frequently resulting in TFAD delays. Medical provider assessment, chest radiograph interpretation, ordering/obtaining blood cultures, and ordering/administering initial antibiotic therapy also caused TFAD delays. The most commonly perceived barriers were patient and x-ray equipment transportation delays and communication delays between providers. The most frequently used strategies to reduce TFAD were stocking antibiotics in the ED and physician education. Focus groups emphasized the importance of multifaceted QI approaches and a top-down hospital leadership style to improve TFAD performance.
  
  
  CONCLUSIONS
  TFAD relies on a series of complex, stepwise processes of care that involve numerous hospital departments and is often delayed by well-described barriers. Addressing these barriers, as well as involving facility leadership in setting institutional QI goals, could possibly improve performance on this pneumonia quality measure.
authors.affiliation: Veterans Affairs Pittsburgh Healthcare System Center for Health Equity Research and Promotion and Geriatric Research, Education and Clinical Center, USA. keri.rodriguez@va.gov
authors.forename: Keri L
authors.initials: KL
authors.lastname: Rodriguez
authors.forename: Kelly H
authors.initials: KH
authors.lastname: Burkitt
authors.forename: Mary Ann
authors.initials: MA
authors.lastname: Sevick
authors.forename: D Scott
authors.initials: DS
authors.lastname: Obrosky
authors.forename: Sherrie L
authors.initials: SL
authors.lastname: Aspinall
authors.forename: Galen
authors.initials: G
authors.lastname: Switzer
authors.forename: Maria K
authors.initials: MK
authors.lastname: Mor
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Fine
mesh_terms: D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D004334:Drug Administration Schedule; D004636:Emergency Service, Hospital / Q000458:organization & administration / Q000592:standards*; D019538:Health Care Surveys; D006787:Hospitals, Veterans; D006801:Humans; D009511:New England; D011014:Pneumonia / Q000188:drug therapy*; D017064:Process Assessment, Health Care; D011785:Quality Assurance, Health Care / Q000379:methods*
chemical_list: D000900:Anti-Bacterial Agents