Hospital vs. nursing home treatment of pneumonia - adapted from the Journal of General Internal Medi

Date: Oct, 1995

Pneumonia in the elderly institutionalized patient often presents a dilemma to the physician, who must decide whether or not to transfer the patient to the hospital for treatment. Fried and colleagues conducted a retrospective cohort study to determine how physicians made this decision and to ascertain which factors were associated with best patient outcome.

Records were reviewed to determine which residents of a single large long-term care facility had a diagnosis of pneumonia (defined as a new respiratory symptom or sign and a new radiographic infiltrate). Patients were excluded if they had not undergone a radiographic evaluation for whatever reason. Each chart was then reviewed to determine the patient's temperature, pulse and blood pressure at the time pneumonia was diagnosed. Functional and cognitive status, other illnesses and evidence of aspiration were also recorded. The time of the initial evaluation was recorded, as was the mode of evaluation (that is, in person or over the telephone). The patient's outcome was also noted.

Possible pneumonia was identified in 351 patients. Of these patients, 346 had charts that were available and 316 fulfilled the study criteria for pneumonia. The mean age of those with pneumonia was 89 years, and 67 percent were women. Severe dementia was noted in 17 percent of these patients, with functional deficit in 31 percent. Charts of 82 percent contained "do not resuscitate" orders and 15 percent contained "do not hospitalize" orders. Of the 68 patients (21 percent) who were evaluated in the hospital, 66 were treated in the hospital. The remaining 248 patients were treated in the nursing home; 189 (77 per cent) received oral antibiotics, 46 (19 percent) received intramuscular antibiotics, and the remainder (4 percent) received intravenous antibiotics. Thirteen (5 percent) were transferred to the hospital after beginning treatment with antibiotics in the nursing home. Two patients did not receive antibiotic treatment, and two patients were evaluated in the hospital but treated in the nursing home. These four patients were excluded, leaving 312 patients for the analysis.

The following factors led to treatment in the hospital: a respiratory rate greater than 40 per minute, a pulse higher than 120 beats per minute, an evaluation done in the evening or over the phone, a temperature greater than 39.1!C (102.5!F), and functional independence. When patients with "do not hospitalize" orders were excluded, tachypnea and evening evaluation were significant factors in hospital evaluation and treatment.

Fifty-eight (88 percent) of the 66 patients who were treated in the hospital were treated successfully. Similarly, 87 percent of the patients treated in the nursing home were treated successfully. Using a multivariate analysis, dependent functional status and use of intravenous antibiotics were identified as the factors associated with death due to pneumonia when treatment was conducted in the nursing home.

The authors conclude that some institutionalized patients with pneumonia could be treated in the nursing home instead of the hospital, with no poorer outcome. Specifically, they recommend using the respiratory rate as one parameter to determine which patients could benefit from the more intensive treatment available in the hospital. However, they caution that the use of hospital resources for the severely demented, functionally impaired patient must be carefully evaluated, since this treatment probably does not provide a substantial benefit. (Journal of General Internal Medicine, May 1995, vol. 10, p. 246.)

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