Reducing Length of Stay for Veterans Hospitalized With Pneumonia

Pneumonia is the 3rd leading medical discharge diagnosis in the VA, and although significant
attention has been focused improving pneumonia process of care measures less attention has
been paid to resource use, specifically length of hospital stay (LOS). Based on our
preliminary analyses LOS is considerably higher in the VA versus other non-federal hospitals.
Major causes of this increased length of stay are delayed conversion from intravenous (IV) to
oral therapy upon reaching clinical stability, and not discharging on the same day as the
conversion to oral antibiotics. Therefore additional interventions are needed to decrease the
LOS for veterans hospitalized with pneumonia in the VA system.

The long-term goal of this research is to develop sustainable approaches to reduce LOS and
thereby improve efficiency of care in veterans admitted with pneumonia to VA Medical Centers
through the implementation of computerized clinical stability reminders. Although prior
research, including our own, has demonstrated moderate effectiveness of resource intense
methods to implement this criteria (e.g., utilization management nurses) new, more effective
and less resource intense, strategies are needed to accomplish this long-term goal. The
design of the computerized clinical stability reminder, the likely range in magnitude of
response to implementation of the intervention, logistics of data collection, data
management, and development of study instruments are needed prior to commencement of a more
definitive, multi-center study. Hence, we are seeking funding to conduct the necessary pilot
work needed to successfully design and implement a large multi-center randomized intervention
study to reduce LOS for veterans with pneumonia.

Our objectives include: 1) Develop and perform a local pilot implementation of an inpatient
clinical reminder within Computerized Patient Record System to identify when veterans
hospitalized with pneumonia are clinically stable and ready for conversion form IV to oral
antibiotic therapy and hospital discharge. 2) Test measures of the constructs of the Theory
of Planned Behavior (TPB) in VA medicine ward physicians and determine if they correlate with
intention and discharge behavior. 3) Establish a collaborative of VA Medical Centers for the
purpose of developing a larger scale implementation study to use evidence-based criteria to
reduce LOS for patients hospitalized with pneumonia. 4) Prepare a VA HSR&D IIR grant proposal
for a cluster randomized controlled trial of a clinical reminder intervention to reduce
length of hospital stay among veterans hospitalized with pneumonia.

The proposed pilot study will develop and implement a computerized-based inpatient clinical
reminder to assist physicians with appropriate conversion from IV to oral antibiotics and
discharge on the same day for veterans hospitalized with pneumonia. In addition to creating
and implementing the clinical reminder at single tertiary care VA teaching hospital, we will
examine physician attitudes and potential barriers/facilitators to the introduction of
inpatient clinical reminders using the theoretical model of TPB. We will also assemble a
cohort of VA medical centers with investigators and chiefs of medical staff willing to
participate in a multi-center randomized control trial of this intervention. The results from
this pilot study will be used to plan a larger, more definitive multi-center trial of this
inpatient clinical reminder with the goal of significantly reducing LOS for veterans
hospitalized with pneumonia in the VA health care system.

Inclusion Criteria:

- Patient hospitalized with outpatient-acquired pneumonia at South Texas Veterans Health
Care System during study period.

Exclusion Criteria: