Cedars-Sinai Medical Center

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Best practice in COPD and pneumonia: old habits left in the cold

As we enter the winter "respiratory" season, physicians are reminded to follow best practices by discharging pneumonia and COPD patients who have achieved clinical stability. According to the Cedars-Sinai Medicine task forces on pneumonia/COPD, there is limited benefit in keeping patients with community-acquired pneumonia or COPD in the hospital once they've met clinical stability criteria. For pneumonia patients, there is no benefit to "observation" after switching from intravenous to oral antibiotics. (For best practices on treating pneumonia and COPD, click the PDF link at the end of this story.)

"Cedars-Sinai physicians are not resistant to change — we want to do the right thing," says Dani Hackner, MD, associate chair of the Department of Medicine and medical director of Case Management. "But it's helpful to remember that while we may have been in the habit of doing what traditionally seemed to be good practice, some of those habits may not be supported by evidence."

Other "habits" that are not supported by evidence: frequent chest X-rays and prescribing bronchodilators such as albuterol and ipratropium routinely in pneumonia cases.

"On the other hand, large volumes of secretions, co-morbid COPD or asthma and active wheezing are clinical indications for bronchodilators," Hackner says. "Patients with bronchiectasis, cystic fibrosis or ciliary dysmotility benefit from bronchodilators. Patients with routine pneumonia, whether it's simple or complex hospital-acquired infections, generally don't need them."

Developing best practices for pneumonia, a common condition that kills 50,000 Americans every year, was one of the first projects addressed by Cedars-Sinai Medicine, a comprehensive initiative launched in 2010 to improve the efficiency, effectiveness and appropriateness of patient care.

Another C-S Medicine task force tackled the common but under-diagnosed condition of COPD, which affects as many as 24 million people in the United States. The task force completed a comprehensive review of the literature and held interdisciplinary meetings to develop treatment guidelines endorsed by the Pulmonary COE. One of its key successes was the reduction of inappropriate use of Xopenex (levalbuterol), an expensive medication not shown to be clinically better than generic albuterol for adults without allergy or malignant arrhythmias to albuterol.

Under the direction of Glenn D. Braunstein, MD, vice president for Clinical Innovation, Cedars-Sinai Medicine aims to ensure the medical center consistently helps patients by doing "the right thing for the right patient in the right setting at the right time with the right resources." Key supporters in the improvement initiatives for respiratory disease include Roy Artal, MD, Michael Lewis, MD, Phillip Zakowski, MD, and Zab Mosenifar, MD.

Guidelines for Treating Pneumonia (PDF)