Clinical pathway for pneumonia: development, implementation, and initial experience.

Background: As part of a large multidisciplinary project to reduce cost, decrease hospital length of stay, and improve efficiency of patient care at Saint Mary's Hospital, a clinical pathway for pneumonia was developed and implemented.

Methods: After using analysis of severity-adjusted data to determine which conditions would be best targets for improvement, a utilization management steering committee created a multidisciplinary group to develop a clinical pathway for pneumonia. This group was led by physician champions and consisted of representatives from nursing, respiratory therapy, pharmacy, and home healthcare. With information gained from chart abstraction, which identified "best practice" patterns, guidance from the medical literature, and local expertise, this group developed a clinical pathway that included an auxiliary protocol for respiratory care and a detailed educational brochure for patients. Before implementing the clinical pathway, extensive educational activities were undertaken involving the medical staff, house staff, nurses, and other staff. Data collected on consecutive patients discharged after implementation of the pathway were compared with data collected on patients discharged before the pathway in 1994.

Results: For DRG 89, the patients who were on the pathway in comparison to the control patients from 1994 had a lower average length of stay by 1.45 days (5.84 vs. 7.29 days) and a lower average total charge by $1,453 ($9,511 vs. $10,964). For DRG 90, the patients who were on the pathway in comparison to the control patients from 1994 had a lower average length of stay by 1.83 days (3.45 vs. 5.28 days) and a lower average total charge by $1319 ($5450 vs. $6769).

Conclusions: The pneumonia clinical pathway that was implemented was associated with reductions in the length of stay and total charges. These reductions were seen in relationship to historical controls and to patients cared for concurrently who were not placed on the pathway. Although not fully used on all pneumonia patients, the presence of the pathway probably had some positive effects even on patients not formally on the pathway, through systems changes and educational influences. The pathway also positively influenced other conditions by the use of ancillary algorithms for conditions other than pneumonia, and the more rapid administration of antibiotics for other infectious diseases. Also, lessons learned in the creation of this first pathway have been helpful in streamlining the process of future pathway development.