Kombolcha General Hospital
4th Q, 2017 Clinical audit
Report on management of community acquired
Pneumonia
By IPD Audit team
Sene/ 2017 E.C
Kombolcha, Ethiopia
Title of Audit
Clinical Audit on the diagnosis and Management of Community-Acquired
Pneumonia in admitted Adult Patients
Audit team
Dr. Yidersal S. (MD, internist) team leader
Mr. Abebaw (Bsc nurse), team member
Mr. Haile Chanyalew, team member
Background and Rationale
Pneumonia is a common cause of hospital admission and a major contributor to
morbidity and mortality worldwide, especially in low-resource settings. Proper
management following guidelines is crucial to improve outcomes. This audit aims
to assess adherence to standard clinical protocols in the diagnosis and
management of community-acquired pneumonia (CAP).
Aim and Objectives
Aim:
To assess the compliance with standard treatment guidelines for community-
acquired pneumonia in adult inpatients
Objectives:
To evaluate documentation of patient’s identification information
To assess the appropriateness of history and physical examination taken
To assess the use relevant investigations for the diagnosis of community
acquired pneumonia
To evaluate appropriateness of diagnosis of community acquired pneumonia
To assess appropriateness of treatment of community acquired pneumonia
To assess monitoring practice for management of community acquire pneumonia
Standards and Criteria
We use the national disease condition priorities audit standards and criteria that found on
audit tool pneumonia prepared by FMOH. These standards and criteria are fit with our
hospital’s practice
Standards/ criteria Target
Patient Identification information documented 100%
Appropriate patient history taken 100%
Appropriate physical examination done 100%
Relevant investigation done 80%
Proper diagnosis of pneumonia made 80%
Appropriate treatment provided 80%
Appropriate monitoring of pneumonia management 100%
Proper discharge information documented 100%
Provider identification information documented 100%
Death while on treatment 10%
Methodology
Audit Type: Retrospective clinical audit
Data Collection Period: 21/07/2017 to 20/10/17 e.c
Sample Size: 19 adult patients admitted with community-acquired pneumonia which is
predetermined by FMOH and we select charts randomly after calculating “K” value
Inclusion Criteria: Adults (age>14years), admitted with CAP
Exclusion Criteria: Hospital-acquired pneumonia
Data Sources: Medical records, treatment charts, investigation reports
Results Summary
S.N Standards/ criteria Target Actual performance
1 Patient Identification information documented 100% 54%
2 Appropriate patient history taken 100% 16%
3 Appropriate physical examination done 100% 14%
4 Relevant investigation done 80% 52%
5 Proper diagnosis of pneumonia made 80% 11%
6 Appropriate treatment provided 80% 37%
7 Appropriate monitoring of pneumonia 100% 32%
management
8 Proper discharge information documented 100% 53%
9 Provider identification information documented 100% 71%
10 Death while on treatment 10% 0.5%
Overall performance 100% 44%
Analysis and Discussion
Strengths: in most of charts provider identification is documented and most patients
received timely investigation and half of patient’s get appropriate antibiotic coverage.
Weaknesses: poor documentation of severity scores, patient’s identification,
appropriate history; physical examination and timely antibiotic initiation were below
standard.
Barriers Identified: shortage of physicians at the time of study periods, lack of
standardized clinical pathways.
Recommendations
1. Introduce CURB-65 scoring checklist in admission notes
2. Train emergency and admitting staff on pneumonia guidelines
3. Develop pneumonia clinical pathway for early diagnosis and treatment
4. Re-audit in 3 months to measure improvement
Action Plan
No Gap identified Action to be taken Responsible Due Date Progressiv
Body e report
1. Introduce CURB-65 Develop CRUB-65 Quality team Within 02 weeks
scoring checklist in
form
admission notes
2. Train emergency and Staff orientation Audit team Next 01 month
admitting staff on
pneumonia guidelines
3. Develop pneumonia Develop flow charts Audit team & Within 02 weeks
clinical pathway for
quality team
early diagnosis and
treatment
4. Re-audit in 3 months Audit Audit team After 03 months
to measure
improvement
Conclusion
This audit revealed relatively good provider identification but highlighted significant gaps
in documentation and timely initiation of care. Implementation of standardized tools and
training can enhance pneumonia management outcomes.
Reference
FMOH clinical audit check list
STG treatment guideline
