Nursing Home Acquired Pneumonia (NHAP) causes excessive morbidity, mortality, hospitalization, and loss of function. At any given time, 1.1-2.5% of veterans who reside at nursing home care units (NHCUs) and State Veterans Homes (SVHs) are ill with pneumonia. Multi-faceted implementation of evidence-based guidelines has been shown to be feasible in the private sector. Retrospective studies demonstrate an association between guideline adherence and improved survival.
Assess the feasibility of a QUERI-like strategy to translate the guidelines into practice at VA-affiliated nursing homes through focus groups, interviews, and a small intervention trial.
Nursing staff focus groups, key informant interviews, and tests of academic detailing (educational outreach) scripts were conducted at five facilities. Based on the information gathered, the QUERI-like intervention was modified and tested at the Florence, Colorado SVH during one influenza season compared to no intervention at a nearby SVH. Forty random SVH nursing staff took an anonymous telephone survey of knowledge and attitudes about NHAP twice prior to the intervention. A second randomly selected group of CNAs and nurses took the survey after the intervention. Research assistants enrolled residents with NHAP, interviewed them and their nurses about their quality of life, assessed their function and reviewed their medical records. The intervention was multifaceted, including (1) a formative phase to tailor implementation and foster staff investment in process and outcomes, (2) institutional level change to facilitate immunization and use of appropriate antibiotics and tests; (3) interactive educational sessions to improve nursing assessment; and (4) academic detailing to physicians to impact diagnostic and prescribing practices. Data were analyzed by Template Analysis Technique for qualitative data; test-retest reliability of the knowledge and attitude survey; exploratory bivariate comparison of intervention delivery and uptake, process of care and outcomes between the intervention and control facilities.
During the formative phase, Medical Directors endorsed the guidelines, but expressed concern about potential liability, cost, differences between the guidelines and current practices, and persuading on-call physicians who provide after-hours coverage to use guideline-driven protocols. Nurses also agreed that guideline compliance would improve care, while noting limitations on direct patient care staff time; communication challenges across levels in a hierarchical system; different cultures on nursing shifts with some shifts being more assertive in seeking care for ill residents; and communication and timing barriers in the care trajectory from detection to appropriate treatment. We modified our intervention to emphasize the availability of pre-printed orders to facilitate guideline-driven care, and the guidelines’ fluidity in guiding treatment at widely differing nursing home settings. We also presented the guidelines at a meeting of the local county medical society, and assisted the intervention facility medical director to revise his advance care planning tool, at his request. The intervention facility rewarded active participation in the study by including work on the project in individual performance evaluations this year.
Twenty-two (22) of the 25 items on the CNA knowledge survey and 41 of the 42 items on the licensed staff version demonstrated at least 70% test-retest agreement. The survey is being modified to shorten it and retain questions that demonstrated the most change between pre and post intervention. Preliminary quantitative analysis of 49 NHAP episodes reveals potentially significant improvements in processes of care at the intervention site, including: more residents and staff vaccinated against influenza; more subjects whose desire for hospitalization was assessed; more chest x-rays ordered; and more consistent use of guideline-recommended antibiotics than at the control facility.
This study demonstrates that multifaceted evidence-based guideline implementation can improve processes of care in a VA-affiliated nursing home for the most common, deadly acute illness in long term care. Knowing whether that this implementation methodology will work in VA-affiliated homes is critical to the VA, because the number of veterans eligible for long term care continues to grow rapidly and will soon exceed 180,000. We are now ready to study NHAP guideline implementation in a national sample of VA affiliated homes, to determine whether guideline implementation improves quality of life, function and mortality outcomes of this debilitating illness.
- Levy C, Hutt E, Pointer L. Site of death among veterans living in Veterans Affairs nursing homes. Journal of The American Medical Directors Association. 2012 Mar 1; 13(3):199-201.
- Hutt E, Ruscin JM, Corbett K, Radcliff TA, Kramer AM, Williams EM, Liebrecht D, Klenke W, Hartmann S. A multifaceted intervention to implement guidelines improved treatment of nursing home-acquired pneumonia in a state veterans home. Journal of the American Geriatrics Society. 2006 Nov 1; 54(11):1694-700.
- Hutt EA, Corbett KK, Bent K, Ruscin JM, Williams EM. Challenges to Implementing Guidelines for Treating Nursing Home-Acquired Pneumonia: A Qualitative Assessment of Variation in Five Settings. Presented at: VA QUERI National Meeting; 2008 Dec 10; Phoenix, AZ.
- Hutt E, Rumsfeld JS, Kramer AM, Williams EM, Liebrecht D, Klenke W, Hartmann S. A Multifaceted Intervention to Implement Guidelines Improved Treatment of Nursing Home-Acquired Pneumonia in a State Veterans Home. Paper presented at: Agency for Healthcare Research and Quality Translating Research Into Practice and Policy Annual Meeting; 2006 Jul 1; Washington, DC.
Aging, Older Veterans' Health and Care, Health Systems
Diagnosis, Treatment - Observational
Long-term care, Quality assurance, improvement