DENVER—What should be done for nursing home patients with pneumonia? “It is crucial to decide whether a patient needs to be in the hospital so that they can be sent there quickly and so that those who can be managed safely in nursing homes are not transferred to the hospital. Those who need antibiotics must get the right ones as soon as possible,” stresses Evelyn Hutt, MD, Assistant Professor of Geriatrics at the University of Colorado Health Sciences Center in Denver and Director of Health Services Research in Long Term Care at the Denver VA Medical Center.

Dr. Hutt and Andrew M. Kramer, MD, Head of the Division of Health Care Policy and Research at the University of Colorado Health Sciences Center, led a panel that recently proposed new guidelines for the management of nursing home–acquired pneumonia.[1] The guidelines address the clinical process from immunization to rapid identification of respiratory symptoms and treatment.

PREVIOUS GUIDELINES WERE BELOW PAR

The guidelines were developed for two reasons: There were no others that dealt adequately with nursing home–acquired pneumonia, and a previous study conducted by Drs. Hutt and Kramer shows that nursing homes often provide insufficient care for residents with pneumonia.[2] “After working for three years in a nursing home rounding service, it was clear to me that there is great variability in how we treat this type of pneumonia,” Dr. Hutt noted in an interview.

Drs. Hutt and Kramer created a first draft of the guidelines based on a literature review. The draft was then revised with the help of a multidisciplinary panel of experts on nursing home–acquired pneumonia.

Each recommendation in the guidelines was graded using a standard system for assessing the quality of the supporting evidence. In that system, grades A, B, and C signify good, moderate, and poor evidence, respectively. In addition, the type of evidence is indicated as follows: Category I requires that there be at least one properly randomized controlled trial; category II is used when there is at least one well-designed nonrandomized trial (cohort or case-controlled analytic studies), multiple time series, or dramatic results in uncontrolled experiments; category III indicates that the recommendation is supported only by the opinions of respected authorities based on clinical experience, descriptive studies, or reports of expert committees.

If no evidence was available to support a recommendation, it was graded “Absent.”

Preparation of the guidelines was underwritten by a grant from Merck & Co; however, no specific drugs were included in the guidelines’ recommendations and no industry representatives were present at the expert panel meeting. Furthermore, the authors acknowledged that only grade CIII evidence is available to support the recommendation of specific drug classes.

KEY RECOMMENDATIONS

A total of 25 recommendations were made; a synopsis of key points is given:

• Vaccination: Nursing home staff and residents should be vaccinated against influenza; residents should also be immunized against Streptococcus pneumoniae (grade AI). Vaccination against S pneumoniae is unnecessary, however, for residents whose records show that they received the vaccine within five years of nursing home admission. Both vaccines are contraindicated for staff and residents who are allergic to them.

• Initial assessment: Nursing assessment for pneumonia should include a full set of vital signs and measurement of oxygen saturation; initial communication with the attending physician about a pneumonia case should occur within two hours of symptom onset (grade Absent). If the nurse does not hear back from the attending physician within one hour, the medical director should be contacted with the help of the director of nursing. The medical director should be asked to assume care of the patient until the attending physician can be reached.

• Diagnosis: Probable pneumonia should be diagnosed in patients with two or more signs and symptoms of pneumonia (grade CIII). Those signs and symptoms include new or worsening cough; newly purulent sputum; temperature above 100.5°F, below 96°F, or 2°F above baseline; respiratory rate greater than 25 breaths/min; tachycardia; new or worsening hypoxia; pleuritic chest pain; decline in cognitive or functional status; and physical findings such as rales or rhonchi on chest examination.

• Patient preferences about care: The patient’s desire for hospitalization and aggressive care should be assessed at the onset of a pneumonia episode; the patient should be asked directly, if possible (grade Absent). The determination can be made by chart review or discussion with a health care proxy if the patient cannot communicate.

• Hospitalization: Decisions about hospitalization should be based on vital signs, active comorbidity, and nursing home capabilities (grade CIII). Hospitalization is recommended for patients with two or more of the following symptoms: less than 90% oxygen saturation on room air at sea level; systolic blood pressure less than 90 mm Hg or 20 mm Hg or more below baseline; respiratory rate above 30 breaths/min or 10 breaths/min more than baseline; the need for three L/min of oxygen more than at baseline; uncontrolled chronic obstructive pulmonary disease, congestive heart failure, or diabetes; unarousability (if previously conscious); and new or increased agitation.

Hospitalization should also be seriously considered for patients with any one of the aforementioned signs or symptoms if the nursing home cannot provide vital sign assessment every four hours. In addition, it should be considered if the nursing home lacks laboratory access, two licensed nurses per shift, or the ability to provide parenteral hydration. Patients with none of the signs or symptoms listed above should be treated in the nursing home unless the patient or proxy insists on hospitalization (grade BII).

• Empiric therapy: The antibiotics selected should cover S pneumoniae, Haemophilus influenzae, Staphylococcus aureus, and common gram-negative rods (grade BII).

• Administration route: Antibiotics for nursing home–acquired pneumonia should be taken orally, if possible (grade AI). Patients being hospitalized should receive one parenteral dose of antibiotics before leaving the nursing home, however. Antibiotic therapy should be administered within four hours of being prescribed by the physician and last 10 to 14 days.

APPROVAL YET TO COME

The guidelines have an important limitation: They have not been approved by any professional society. “We want to test the guidelines prospectively with a control group before seeking official approval to be sure that they can be implemented and that they will make a difference,” related Dr. Hutt.

In the meantime, nursing homes can and should use the guidelines to the fullest extent possible because there is strong evidence and an expert consensus to support them, she and Dr. Kramer assert.

—Timothy Begany

References
1. Hutt E, Kramer AM. Evidence-based guidelines for management of nursing home-acquired pneumonia. J Fam Pract. 2002;51:709-716.
2. Hutt E, Frederickson E, Kramer AM. Association between quality of care and survival in nursing home acquired pneumonia. Presented at: American Geriatrics Society 58th Annual Meeting; May 9-13, 2001; Chicago, Ill.

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