Evidence-based guidelines for management of nursing home-acquired pneumonia

Modified delphi process

A multidisciplinary, multispecialty panel was recruited from nationally recognized experts in nursing home-acquired pneumonia, geriatric and infectious disease pharmacology, pneumonia treatment guideline development, and nursing home nurses (see Appendix). Panel members received an annotated version of the draft guidelines with a bibliography and the questionnaire described below. A table of the activity spectrum of currently available antibiotics, a table summarizing published reports on the microbiology of nursing home-acquired pneumonia (see Table 1), and tables summarizing our retrospective study of care processes in nursing homes and 30-day survival¹¹were also included in that mailing.

The questionnaire asked whether each proposed guideline was clear, specific, feasible, measurable, and commensurate with his or her usual practice. Panelists were also asked to score each proposed guideline on its importance in determining the outcome of a nursing home-acquired pneumonia episode on a 5-point Likert scale, with 1 being not important and 5 being extremely important. Suggestions for substantive changes were elicited. The questionnaires were returned 2 weeks before an all-day, face-to-face meeting. For each guideline we calculated the percentage of panelists who agreed that it met each of the 5 criteria outlined. The means and standard deviations of the guideline weights were analyzed. Suggestions for substantive changes in the guidelines were collated and presented in tabular form, along with results of the survey, at the beginning of the meeting.

The most controversial guidelines were found to be classification of symptoms into a diagnosis of probable pneumonia, criteria for hospitalization, evaluation and treatment of residents not being hospitalized, and antibiotic choice. Less controversial were recommendations for immunization and treatment duration. The panel meeting devoted 2 hours to each of the 4 most controversial guidelines. The draft guideline was read and results of the pre-meeting ratings and suggestions were discussed. The guidelines were revised substantially and voted on. A care pathway was also developed at the meeting.

Because revisions were extensive and 1 of the panelists was participating by telephone, a copy of the revised guidelines and care pathway was sent to the panelists for further review and comment after the meeting. At that time, they were asked to rate each guideline on how confident they were that the recommendation should be included as part of the proposed guidelines using a 5-point Likert scale, with 1 denoting not confident and 5 denoting very confident. Because the lowest mean confidence rating was 3.4 after this iterative process, no guidelines were dropped from the set agreed upon at the meeting. Final revisions were made to the guidelines and their respective strength-and-quality-of-evidence grades, and approved by the panel.

TABLE 1
Nursing home pneumonia etiology according to studies using verified sputum* or blood culture

Recommendations

Each of the 25 guidelines is presented below. The strength and quality of evidence rating and panelists’ mean confidence score are shown in parentheses.

Prevention

1. Residents should be vaccinated against Streptococcus pneumoniae at admission unless there is documentation of vaccination within 5 years preceding admission or they were allergic to previous pneumococcal vaccine. (A/I/4.7)^22-27
2. Residents should be vaccinated against influenza by December of each year if they are not allergic to eggs or previous influenza vaccine. Residents admitted between December and March should be vaccinated if not already immunized for the current influenza season, and they are not allergic as described above. (A/I/5.0)^27,28
3. The nursing facility should provide and strongly recommend immunization against influenza for all employees by December of each year if the employee is not allergic to eggs or previous vaccine. (A/I/4.9)^29,30

Initial evaluation of residents with respiratory impairment

Once a resident has been noted to have a significant change in respiratory status, the clinician should use the care pathway outlined in (Figure 1). The panel believed that nurse practitioners and physician assistants with appropriate supervision could substitute for physician care in all pathway activities. Guideline recommendations 4 through 8 address the rapid recognition and physician notification of serious respiratory symptoms:

1. Physicians with nursing home residents should be available or have cross-coverage by pager 24 hours/day, 7 days/week. (Absent/Absent/4.8)
2. Nursing home staff should page the physician within 1 hour when a resident is noted to have any 2 of the following signs or symptoms: new or worsening cough; increased or newly purulent sputum; decline in cognitive, physical, or functional status; fever; hypothermia; dyspnea; tachypnea; chest pain; or new or worsening hypoxemia. (Absent/Absent/4.3)
3. Nurse evaluation at symptom onset should include, at least, vital signs (temperature, pulse rate, respiratory rate, and blood pressure) and oxygen saturation if a pulse oximeter is available in the facility. (Absent/Absent/4.5)
4. When notified as in guideline #5, the physician should call back within 1 hour. (Absent/Absent/4.3)
5. If the nurse does not hear back from the physician within 1 hour, he or she should notify the director of nurses or designee. The nurse and the director of nurses should agree on a plan to notify the medical director or designee and ask him or her to assume care of that episode until the medical director can contact the attending physician. (Absent/Absent/3.5)