From zero to 100 in six months

Cincinnati Children's Hospital Medical Center initiative targeted pneumonia treatment.

Where: Cincinnati Children's Hospital Medical Center (CCHMC), a tertiary care, pediatric academic medical center with 523 licensed inpatient beds at two locations in Ohio.

The issue: Achieving compliance with new guidelines for treating pneumonia in pediatric inpatients.


In August 2011, the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America published a guideline on management of community-acquired pneumonia (CAP) in children. “We noticed that the current guideline at Cincinnati Children's Hospital was similar but not equal,” said Lilliam Ambroggio, PhD, a fellow in the Division of Hospital Medicine at CCHMC.

However, the hospital had no formal antimicrobial stewardship program in place, so Dr. Ambroggio and colleagues took it upon themselves to change the prescribing habits of their colleagues. They formed a multidisciplinary team, with representatives from hospital medicine, emergency medicine, pharmacy and nursing, to develop and test interventions to implement the guideline.

How it works

The first intervention, in October 2011, was a seminar explaining the guidelines to fellows and attendings in hospital medicine, pulmonology, infectious diseases and the emergency department. Each attendee got a one-page summary to distribute to anyone who hadn't made the seminar. Then, in January 2012, residents were taught about the guideline during morning report. The team also created an index card with recommended antibiotics listed as bullet points.

In April, the team modified the hospital's electronic medical record (EMR) to match the CAP order set to the new guidelines and provide a link to the guidelines. In May, the guidelines were emailed to the entire hospital.


To determine the effects of their work, the researchers started by assessing pneumonia discharges from May to October 2011 (before any interventions) and found that 0% of emergency department prescribing for patients met the guideline; this figure was 30% for the hospitalist service. After the seminar, those rates shot up to 82% and 90%, respectively.

By the time the series of interventions was complete—about six months after the program started—compliance with guidelines on the two services had reached 100%. It stayed that way for the next three months, according to results published in the May Pediatrics.

“I don't think anybody expected such a big change. We were hopeful of having a change up to about 80%. We didn't expect to go up to 100%, or to do so in that short a time period,” said Dr. Ambroggio.

“It's hard to tease out which [intervention] specifically had the biggest effect. I think they all sort of built on each other,” she added.


“In general, the things that we were trying to encourage were not terribly controversial,” Dr. Ambroggio said. But the project leaders did get responses in the seminar that proved the value of disseminating guidelines in an open forum. “People had a lot of questions… ‘Why don't we prescribe this? And why are we prescribing that?’” she described. “There was a huge educational piece to it.”

Next steps

Based on this success, the Cincinnati project leaders plan to apply the same method to additional components of the pediatric guidelines. “We're trying to take some of the other ones, like the ordering of blood cultures for a patient who is admitted with pneumonia, and trying to also do quality improvement on that as well,” said Dr. Ambroggio.

The effort is moving outside the hospital, too. “We're also trying to expand what we did in the hospital out to community practices in the area and try to get their prescribing, if it's not already, to match with the recommendation for outpatient settings,” she said.

Words of wisdom

“Really listen. That seems like such an easy thing,” said Dr. Ambroggio. “But…every division and every service has a slightly different way that they do things. Being able to plug into the different systems and looking at the entire continuum of care is very important.”