Improving care for nursing home-acquired pneumonia in a managed care environment.

OBJECTIVE: To characterize care of nursing home residents who became ill with nursing home-acquired pneumonia (NHAP) in a group-model, nonprofit HMO, and to pilot-test a strategy to implement evidence-based NHAP care guidelines. STUDY DESIGN: Medical record review and intervention pilot test. METHODS: Nursing home medical records of 78 patients who developed NHAP in 6 homes where the HMO contracts for Medicare services were reviewed for demographics, functional status, comorbidity, NHAP severity, care processes, and guideline compliance. The intervention, combining organizational change (facilitating immunization and providing appropriate emergency antibiotics) and education (quarterly in-services for nursing and aide staff), was pilot-tested for 7 months in 1 facility. Measures of baseline and intervention guideline adherence at that facility were compared with Fisher's exact test. RESULTS: Among the patients with NHAP, 83% had a response from their physician in less than 8 hours, 82% were treated with an antibiotic that met spectrum recommendations, and 74% were able to swallow were treated with oral antibiotics. However, few patients had documentation of influenza and pneumococcal vaccination; less than half the direct care staff had been vaccinated; and nursing assessments were incomplete for 23%. At the pilot-test facility, improvement was seen in influenza vaccination (14% to 52%, P = .01) and use of the most appropriate antibiotics (47% to 85%; P = .03). The guideline adherence score improved from 52% to 63% (P = .04). CONCLUSION: Use of a multidisciplinary, multifaceted intervention resulted in improvement in quality of care for nursing home residents who become ill with pneumonia.

Associations among processes and outcomes of care for Medicare nursing home residents with acute heart failure.

OBJECTIVE: To characterize Medicare skilled nursing facility (SNF) residents who become acutely ill with heart failure (HF) and assess the association between the outcomes of rehospitalization and mortality, and severity of the acute exacerbation, comorbidity, and processes of care. DESIGN: SNF medical record review of Medicare patients who developed an acute exacerbation of heart failure (HF) during the 90 days following nursing home admission. SETTING: A total of 58 SNFs in 5 states during 1994 and 1997. PARTICIPANTS: Patients with 156 episodes of acute HF among 4693 random Medicare nursing home admissions. MEASUREMENTS: Demographic variables, symptoms, signs, comorbidity, nursing home characteristics, nurse staffing ratios, and processes of care were compared between acute HF subjects transferred to hospital and those not transferred; and between subjects who died within 30 days of an acute exacerbation and those who survived. RESULTS: After adjusting for age, disease severity, and comorbidity, residents whose change in condition was evaluated during the night shift were more likely to be hospitalized (OR 4.20, 95%CI 1.01-17.50). Residents who were prescribed an angiotensin-converting enzyme inhibitor or who received an order for skilled nursing observation more often than once a shift were 1/3 as likely to die as those who did not (OR 0.303, 95%CI 0.11-0.82), after adjusting for hypotension, delirium, do not resuscitate orders, and prior hospital length of stay. CONCLUSION: For residents who develop an acute exacerbation of HF during a SNF stay, there is an association between attributes of nursing home care and the outcomes of rehospitalization and mortality.

Precipitants of emergency room visits and acute hospitalization in short-stay medicare nursing home residents.

OBJECTIVES: To determine what precipitates rehospitalization for residents who become acutely ill in the first 90 days of a nursing home (NH) admission. DESIGN: NH medical record review comparing acutely ill Medicare admissions transferred back to hospital with those not transferred. SETTING: Sixty skilled nursing facilities in five states during 1994. PARTICIPANTS: Six hundred thirty-six residents who became acutely ill with urinary tract infection (UTI), pneumonia, or congestive heart failure (CHF) during the first 90 days of their nursing home admission were identified from 2,414 random NH Medicare admissions, excluding those with orders not to be hospitalized. MEASUREMENTS: Diagnosis, age, gender, advance care directives, nursing shift during which problem occurred, comorbidity, symptoms, and signs of acutely ill NH residents transferred to the hospital or emergency department were compared with those not transferred. RESULTS: Rates of hospitalization varied markedly by acute illness: 11 of residents with UTI, 46 with pneumonia, and 58 with an exacerbation of CHF (P< .001). In stratified multivariate analysis, older age decreased the odds of rehospitalization only for CHF. Male gender increased odds of hospitalization for pneumonia (odds ratio (OR) = 2.94) and decreased odds of hospitalization for CHF (OR = 0.28). Do not resuscitate orders were negatively associated with hospitalization only for pneumonia (OR = 0.23), whereas weekend and evening/night shifts increased odds of hospitalization for UTI. Each illness had its own set of symptoms, signs, and comorbidities associated with hospitalization. CONCLUSIONS: Whether an acutely ill NH Medicare patient was rehospitalized depended primarily on the particular illness. The relative importance of age, gender, shift, advance care directives, symptom severity, signs, and comorbid illnesses varied by diagnosis.