Algorithm Aids Decision on Pneumonia Hospitalization

A clinical pathway algorithm has been developed that enables doctors to decide when nursing home residents with pneumonia can be treated in the nursing home and when they should be treated in a hospital.

To test the safety and feasibility of the clinical pathway algorithm, researchers from McMaster University (Hamilton, Ontario, Canada) selected ten nursing homes that were randomly assigned to use the clinical pathway, while other homes followed their usual care practices. In either case, when a patient exhibited symptoms of a lower respiratory tract infection, the staff at the nursing home would obtain chest x-rays using a mobile unit. These were the patients who were eligible for inclusion in the study.

A nurse would then determine if the patients met five criteria. They could eat and drink, had a pulse of no more than 100/min, a respiratory rate of < 30/min, systolic blood pressure of 90 mm Hg or higher, and oxygen saturation of at least 92% (90% or more for residents with chronic obstructive pulmonary disease, or COPD). If any one of those five criteria was not met, the algorithm stipulated that the patient be transferred to a hospital. Otherwise, the patient would remain in the nursing home and be treated with levofloxacin 500 mg orally for 10 days and hypodermoclysis if dehydrated.

The researchers followed a total of 327 patients in the clinical pathway group and 353 in the usual care group. Thirty-four residents in the algorithm group (10%) and 76 (22%) in the usual care group were hospitalized. Based on their symptoms, 18 (24%) of those in the usual care group who had been hospitalized would have remained in the nursing home if the protocol had been followed. The mortality rates were similar between groups. The results were reported in the June 7, 2006, edition of the Journal of the American Medical Association (JAMA).



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