Objective Findings Focused on “Bedside Criteria” Are Key to Pneumonia Diagnoses in Nursing Homes
The diagnosis of pneumonia in the nursing home setting should be made based on objective findings focused on the respiratory tract and obtained via “bedside criteria,” according to an article in the March issue of JAMDA.
In Nursing Home-Associated Pneumonia: Part I, Diagnosis, the author, Joseph M. Mylotte, MD, described main bedside criteria as cough, shortness of breath, elevated respiratory rate (>25/per minute), reduced oxygen saturation (<94% on room air or decrease of >3% from baseline saturation), and an abnormal chest exam. Two or more of these factors should be present for a diagnosis of pneumonia. Dr. Mylotte also suggested secondary criteria that should be considered, including fever, change in mental status, or change in functional status. The care team also should determine if there are risk factors for aspiration such as history of stroke, dysphagia of any cause, Parkinson’s disease, presence of a feeding tube, and/or excess sedation. If the main criteria are met, the author said, a chest X-ray should be obtained.
In instances where aspiration is an issue, it is important to distinguish between pneumonia and pneumonitis, a term usually referring to noninfectious causes of lung inflammation. A decision tool for this purpose has been proposed, according to the article, but not validated. In terms of tests, Dr. Mylotte indicated that the chest X-ray is most important, although this may be misinterpreted. Lung ultrasound as an adjunct to or replacement for the chest X-ray needs to be studied, he suggested.
Dr. Mylotte stressed that documentation of the findings resulting in a diagnosis of pneumonia is an important component of monitoring quality of nursing home care. This is especially true, he said, as “pneumonia is one of the three most common infections identified in nursing home residents and is associated with the highest mortality of any infection in this setting.”
Nursing Home-Associated Pneumonia, Part II: Etiology and Treatment, also in the March issue of JAMDA, concluded that most nursing home residents with pneumonia can be treated successfully in the nursing home. In this article, Dr. Mylotte stated, “There is an urgent need for a specific nursing home-acquired pneumonia diagnosis and treatment guideline that will give providers guidance in the management of this infection in the nursing home.”
This study was conducted Dr. Mylotte at the Department of Medicine, Division of Infectious Diseases, Jacobs School of Medicine and Biomedical Science, State University of New York at Buffalo.
JAMDA is the official journal of AMDA – The Society for Post-Acute and Long-Term Care Medicine. JAMDA publishes peer-reviewed articles including original studies, reviews, clinical experience articles, case reports, and more, on all topics more important to post-acute and long-term care medicine. Visit www.jamda.com for more information.
About AMDA – The Society for Post-Acute and Long-Term Care Medicine
AMDA – The Society for Post-Acute and Long-Term Care Medicine is the only medical specialty society representing the community of over 50,000 medical directors, physicians, nurse practitioners, physician assistants, and other practitioners working in the various post-acute and long-term care (PALTC) settings. Dedicated to defining and improving quality, we advance our mission through timely professional development, evidence-based clinical guidance, and tireless advocacy on behalf of members, patients, families, and staff. Visit www.paltc.org for more information.