Title : Evaluating the diagnosis and management of community-acquired pneumonia in a UK hospital trust
Abstract:
Background: Community-acquired pneumonia (CAP) accounts for over 100,000 hospital admissions a year in the United Kingdom (UK). There is a need for a standardisation of the diagnosis and management of CAP, further highlighted by the variation in the number and length of CAP admissions across the UK.
British Thoracic Society (BTS) audits also show that the rates of hospital re-admission following CAP are rising, as well as overall in-hospital mortality rates.
Aim: The aim of this audit was to identify the rate of compliance and attainments within the OUH trust of the national recommendations that would allow for a more standardised approach in the diagnosis and management of CAP across the UK.
Methods: An audit of 110 patients admitted to Oxford University Hospitals NHS Foundation Trust (OUH) in January 2023, and 34 patients in January 2024, who had a documented antibiotic indication of CAP.
25 patients from each group that had a chest x-ray on admission (22.7% for 2023, 73.5% for 2024) were included in the analysis. Parameters assessed included: if the chest x-ray was timely (within 4 hours of admission); if there was a chest x-ray interpretation documented in the patients’ notes; documentation of a CURB-65 score, treatment escalation plan (TEP) and smoking status. We also looked at whether NRT and smoking cessation was offered where appropriate, if a letter explaining the diagnosis was provided, and if a 6-week follow up chest x-ray was arranged. Finally, we looked at how many of these patients were readmitted within 3 months with another CAP.
Results:
|
Parameter assessed |
2023 |
2024 |
|
CXR performed |
100% |
100% |
|
CXR performed within 4 hours of admission |
80% |
92% |
|
CXR interpretation documentation |
92% |
80% |
|
CURB-65 score documentation |
8% |
8% |
|
TEP documentation |
48% |
24% |
|
Smoking status documentation |
48% |
68% |
|
NRT offered if appropriate |
100%* |
18% |
|
Smoking cessation offered if appropriate |
0% |
9% |
|
Letter provided |
0% |
9% |
|
6-week follow up CXR arranged |
16% |
4% |
|
Readmitted due to CAP |
4% |
8% |
* Only 1 patient documented to be a smoker in 2023 cohort.
Conclusions: The trust performs well in carrying out CXRs within 4 hours of admission for all patients with suspected CAP, as well as documenting the interpretation of the CXR – this was mostly documented in the post-take consultant ward round notes. This is particularly valuable in the management of patient prior to obtaining formal radiology reports.
There was poor documentation of a CURB-65 score which would allow severity of pneumonia and appropriate most antibiotics to be considered.
There is also a need for improvement in the documentation of TEPs and smoking status. Furthermore, in the 2024 cohort, it was found that the only patients offered smoking cessation advice were those identified by the inpatient Tobacco Dependency (TD) team, highlighting the potential to increase inpatient TD team referrals.
Finally, improvements are needed to increase the rates of provision of written information leaflets explaining the diagnosis, and follow-up CXR arrangements.
The audit results have allowed useful insights into the diagnosis and management of CAP within the trust over two different time-periods – this includes identification of areas in which the trust continues to perform well in, and areas that still require improvement. This will allow initiation of specific quality improvement projects, some of which have already been initiated, to help create a standardised approach to improve the management of the increasing number of CAP hospital admissions, and to reduce rates of mortality and readmission.
