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.

DESIGN

Cluster-randomized, controlled trial.

SETTING

32 emergency departments in Pennsylvania and Connecticut.

PATIENTS

3219 patients with a clinical and radiographic diagnosis of pneumonia.

INTERVENTIONS

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).

MEASUREMENTS

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.

LIMITATIONS

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.