Use of a Critical Pathway to Reduce LOS in Patients with CAP

Every year, an estimated 4 million people in the United States develop community-acquired pneumonia (CAP). There were 1.3 million hospitalizations for pneumonia in 2005. The cost of care for patients with CAP, including direct and indirect costs, is an estimated $40 billion annually.

The largest component of the cost of CAP is length of hospital stay (LOS). In addition, longer stays put patients at risk for complications such as phlebitis, pulmonary embolism, and nosocomial infection. There are variations in LOS for CAP, suggesting that there is no uniform strategy used by physicians to determine the correct time for hospital discharge.

LOS is determined, in large part, by the duration of intravenous (IV) antibiotic therapy. According to researchers, switching from IV to oral therapy once patients are clinically stable may help shorten LOS and thus reduce the costs of care for patients with CAP.

Critical pathways are being used increasingly by healthcare facilities as a strategy for decreasing cost and improving quality of care; however, data on the effects of critical pathways for CAP are scarce. Researchers recently designed a randomized trial to test the hypothesis that the use of a 3-step critical pathway would be as safe as, and more effective than, usual care in reducing the duration of IV antibiotic therapy and LOS in patients with CAP. They reported the results in Archives of Internal Medicine [2012;172(12):922-928].

The primary end point was LOS. Secondary end points were the duration of IV antibiotic therapy, adverse drug reactions, need for readmission, overall case-fatality rate, and patient satisfaction with care.

Patients were enrolled and randomly assigned to follow a 3-step critical pathway or to receive usual care. The 3 steps of the critical pathway were: (1) early mobilization of patients; (2) use of objective criteria for switching to oral antibiotic therapy; and (3) use of predefined criteria for deciding on hospital discharge.

Early mobilization was defined as movement out of bed with a change from the horizontal to the upright position for at least 20 minutes during the first 24 hours of hospitalization, with progressive movement each subsequent day. Switching patients from IV to oral therapy was done when they experienced clinical improvement and met eligibility criteria (ability to maintain oral intake, stable vital signs, and absence of exacerbated major comorbidities and/or septic metastases). The predefined criteria for hospital discharge were meeting the criteria for switching to oral antibiotic, baseline mental status, and adequate oxygenation on room air. The criteria for switching to oral therapy and hospital discharge could be met simultaneously or sequentially.

The study assigned 401 patients to follow the 3-step critical pathway (n=200) or to receive usual care (n=201). In the 3-step group, median LOS was 3.9 days compared with 6.0 days in the usual care group (difference, -2.1 days; 95% confidence interval [CI], -2.7 to -1.7; P<.001). Median duration of IV antibiotic therapy was 2.0 days in the 3-step group compared with 4.0 days in the usual care group (difference, -2,0 days; 95% CI, -2.0 to -1.0; P<.001).

More patients in the usual care group experienced adverse drug reactions (4.5% vs 15.9%; difference, -11.4 percentage points; 95% CI, -17.2 to ­5.6 percentage points; P<.001).

There were no significant differences in the development of in-hospital complications and overall mortality between the 2 groups. Likewise, the numbers of patients requiring readmission were similar between the groups, as was patient satisfaction with care.

Noting that the use of the 3-step pathway was safe and effective in reducing the duration of IV therapy and LOS, the researchers commented, “Such a strategy will help optimize the process of care of hospitalized patients with CAP, and hospital costs would be reduced.”