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 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.