Once the physician has been notified, he or she must decide whether pneumonia is a leading consideration in the diagnosis of the reported change.
- The physician and nursing home staff should concur that pneumonia is a leading consideration in the diagnosis of the change noted in guideline #5 above, if the patient has 2 or more of the following signs or symptoms: new or worsening cough; newly purulent sputum; fever of 100.5°F or 2°F more than baseline; hypothermia < 96°F; dyspnea; respiratory rate > 25 breaths per minute; tachycardia; new or worse hypoxemia; pleuritic chest pain; a decline in cognitive or functional status; or new rales or rhonchi on chest examination. Such patients will be referred to in the remainder of the guidelines as having “probable pneumonia.” (C/III/4.1)5,31
FIGURE
Care pathway for nursing home-acquired pneumonia
Venue of care
Once pneumonia is considered likely, the physician must decide whether to hospitalize the resident. Because nursing home-acquired pneumonia is frequently the terminal event of a long and debilitating illness, this decision is especially important.
- The patient’s desire for hospitalization and aggressive care should be assessed directly if possible, or by chart review or discussion with the patient’s health care proxy. Patients with prior orders for no hospitalization or who refuse hospitalization (personally or by proxy) should not be hospitalized. (Absent/Absent/4.8)32
For patients willing to be hospitalized, the panel suggested categorization into 1 of 3 groups: patients whose severity of illness mandates hospitalization; patients whose severity of illness is such that the nursing home’s capacity to deliver acute care should be considered; and patients so stable that treatment in the nursing home is preferable. This set of recommendations is based on 2 retrospective series which suggest that only patients with elevated respiratory rates benefit from hospitalization2 and that patients hospitalized according to criteria similar to these tended to have better survival.11 These recommendations are modeled after Fine’s prediction rule to identify low-risk patients with community-acquired pneumonia,33 and take into account the mortality prediction model of Naughton and coworkers34 for nursing home-acquired pneumonia.
- Patients with 2 or more of the following symptoms should be hospitalized (C/III/4.1)2,11:
- If the nursing home cannot provide vital sign assessment every 4 hours, laboratory access, parenteral hydration, and 2 licensed nurses per shift in the facility, serious consideration should be given to hospitalizing patients with any one of the above. (C/III/4.1)11,35,36
- Patients with none of the above should be treated in the nursing home unless the patient or proxy insists on hospitalization. (B/II/4.5)2,11,33,34
Evaluating and monitoring patients who remain in nursing homes
- Nurse evaluation each shift should include, at least, vital signs with measured respiratory rate and oxygen saturation until symptoms resolve. (C/III/4.5)16,17,37
Although a study published by Mehr and colleagues38 after the panel proceedings suggested that patients with multiple signs and symptoms of nursing home-acquired pneumonia are so likely to have an infiltrate on chest x-ray that treating without first obtaining an x-ray may be acceptable, the panel recommended that:
- Patients with probable pneumonia should have a chest x-ray. (C/III/4.2)15,39
- Patients with probable pneumonia should be evaluated in person by the physician, ideally within 24 hours and certainly within 72 hours. (Absent/Absent/4.5)
- Because of the issue of antibiotic resistance, and not because of anticipated direct patient benefit, patients for whom antibiotics are ordered should have 1 blood culture drawn if this can be accomplished without delaying initiation of antibiotics longer than 1 hour. (C/III/3.4)37,40
The panel did not recommend sputum Gram’s stain and culture even though 2 recent guidelines on evaluating infection in long-term care facilities did.15,16 Obtaining high-quality sputa in this population is notoriously difficult.1
TABLE 2
Key recommendations of evidence
| Guideline | Strength/quality of evidence |
|---|---|
| 1, 2, 3: Vaccinate staff and residents against influenza and residents against Streptococcus pneumoniae. | A/I |
| 4, 5, 6, 7, 8: Nursing assessment of change in condition should include a full set of vital signs with oxygen saturation. Initial communication with the physician should be completed within 2 hours of symptom onset. | Absent |
| 9: Probable pneumonia is defined as 2 or more of the following: new or worsening cough; newly purulent sputum; temperature > 100.5°F, < 96°F, or 2°F more than baseline; respiratory rate > 25 breaths per minute, tachycardia; new or worsening hypoxia; pleuritic chest pain; decline in cognitive or functional status; physical findings on chest examination such as rales or rhonchi. | C/III |
| 10: Patient’s desire for hospitalization and aggressive care should be assessed at the onset of the episode and directly with the patient, if possible. | Absent |
| 11, 12, 13: The decision to hospitalize should be based on a combination of vital sign criteria, active comorbidity, and nursing home capabilities. | C/III |
| 23: The antibiotic chosen as empiric therapy should cover S pneumoniae, Haemophilus influenzae, common gram-negative rods, and Staphylococcus aureus. | B/II |
| 25: Use oral antibiotics if the patient can take oral medication. | A/I |
| Recommendations were graded according to a standard system,19with 3 categories for recommendation strength (A, good evidence; B, moderate evidence; C, poor evidence) and 3 grades for quality of evidence (I, at least 1 properly randomized, controlled trial; II, at least 1 well-designed clinical trial without randomization from cohort or case-controlled analytic studies, multiple time series, or dramatic results in uncontrolled experiments; III, opinions of respected authorities based on clinical experience, descriptive studies, or reports of expert committees). | |