Life In The Slower Lane

Here is the PICO analysis for the thirty-third uploaded article:

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✅ PICO Analysis

Full Article Title:

Impact of a Multidisciplinary Intervention on Antibiotic Use for Nursing Home–Acquired Pneumonia

Type of Study:

Quasi-experimental, mixed-methods, multicentre intervention study

Journal and Year:

The American Journal of Geriatric Pharmacotherapy (2011); 9(6):442–450.e1

DOI: 10.1016/j.amjopharm.2011.09.009

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P – Population

• Setting:
  • 16 nursing homes in Colorado (intervention) and Kansas/Missouri (control)
• Participants:
  • Nursing home residents with ≥2 signs/symptoms of lower respiratory tract infection (LRTI)
  • Total of 1123 NHAP episodes analysed: 549 in the intervention group, 574 in control

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I – Intervention

• Multifaceted, multidisciplinary intervention, including:
  1. Academic detailing to physicians and mid-level providers regarding guideline-concordant antibiotic prescribing and diagnostics
  2. Quarterly education sessions for nursing staff on NHAP symptom recognition and early treatment
  3. Use of preprinted orders and laminated care pathways (see Figure 1 on page 5)
  4. Liaison nurses designated in each facility as change agents
  5. Incentives for facilities ($1000 per year for participation) 
• Duration:
  • Baseline year + 2-year intervention period (2005–2007)

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C – Comparison

• Control group:
  • 8 matched nursing homes in Kansas and Missouri with no intervention
• Comparison strategy:
  • Adherence to NHAP antibiotic guidelines pre- vs post-intervention between groups

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O – Outcomes

Primary Outcomes (Adherence to NHAP Guidelines):

1. Timeliness of antibiotic initiation (within 4 hours of clinician order):
   • Increased from 57% to 75% in intervention homes
   • Decreased from 38% to 31% in control homes
   • Statistically significant improvement (P = 0.0003) 
2. Optimal antibiotic choice (anti-pneumococcal fluoroquinolone or β-lactam + macrolide):
   • Intervention: 60% to 66%
   • Control: 32% to 39%
   • No significant difference between groups (P = 0.3)
3. Appropriate duration of therapy (10–14 days):
   • Declined in both groups (intervention: 27% to 13%; control: 24% to 19%)
   • Likely affected by evolving practice trends toward shorter courses 

Secondary Outcomes:

• Mortality:
  • No significant difference (intervention 7.3%, control 9.9%; P = 0.115)
• Antibiotic treatment correlated with chest X-ray findings:
  • Positive CXR = 5x more likely to receive antibiotics
  • Associated with longer antibiotic course (6.5 vs 5.5 days, P < 0.01)

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Outcome Classification

• Person-centred outcomes:
  • More timely treatment for NHAP likely contributed to improved comfort and potentially better outcomes, though no mortality difference was detected
• Process outcomes:
  • Statistically significant improvement in time to antibiotic initiation
  • Modest, non-significant improvement in antibiotic choice adherence
  • No improvement in adherence to duration recommendations
• Health system outcomes:
  • No impact on hospitalisation or mortality, but results support feasible implementation of nurse-led interventions to improve processes

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Summary Conclusion

This well-structured, multicentre intervention targeting NHAP guideline implementation demonstrated significant improvement in the timeliness of antibiotic administration but had limited effect on prescribing practices or treatment duration. The positive results were largely attributed to repeated nurse education and local leadership support. In contrast, academic detailing of physicians was limited in frequency and intensity, potentially explaining the weak impact on prescribing habits. The study highlights that process improvements are achievable in nursing homes, but changing entrenched clinician behaviours requires more sustained engagement .

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