Life In The Slower Lane

Here is the PICO analysis for the article:

Full Article Title:

A Multifaceted Intervention to Implement Guidelines Improved Treatment of Nursing Home–Acquired Pneumonia in a State Veterans Home

Authors: Hutt E, Ruscin JM, Corbett K, Radcliff TA, Kramer AM, et al.

Journal: Journal of the American Geriatrics Society (JAGS) (2006); 54(11):1694–1700

DOI: 10.1111/j.1532-5415.2006.00937.x

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✅ PICO Analysis

Type of Study:

Quasi-experimental pre–post design with an untreated control group

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P – Population

• Setting:Two State Veterans Homes (SVHs) in Colorado:
  • Intervention site: 134-bed rural facility in Florence, CO
  • Control site: 120-bed hospital-based facility in Walsenburg, CO
• Participants:
  • 86 residents (46 intervention, 40 control) with symptoms suggestive of lower respiratory tract infection (e.g., cough, sputum, dyspnoea, fever, functional/cognitive decline)
  • Excluded if within 5 days of admission, expected to die within 48 hours, or declined consent
• Resident Characteristics:Mostly male, average age 81, with high rates of cognitive and functional impairment and multiple comorbidities

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I – Intervention

Multifaceted Guideline Implementation Strategy, including:

1. Formative phase:
   • Local adaptation of NHAP clinical guidelines
   • Identification of barriers and site-specific champions (liaison nurse)
2. Institutional Changes:
   • Preprinted orders
   • Antibiotics and diagnostic tools made available
   • Vaccination policy review
3. Nursing Level Implementation:
   • Mandatory staff development in-services for CNAs and nurses
   • Distribution of guideline materials (pocket cards, posters)
4. Physician-Level Academic Detailing:
   • Meetings with physicians and mid-level providers
   • Emphasis on diagnostic and treatment pathways (e.g., antibiotic timing, X-ray use, influenza vaccination)

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C – Comparison

• Control Group:
  • A similar SVH with no formal intervention
  • Compared guideline adherence pre- and post-intervention between the two sites over two influenza seasons (2003–04 and 2004–05)

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O – Outcomes

Person-Centred Outcomes:

• Mortality and hospitalisation rates were tracked but showed no statistically significant differences due to small sample size (15% mortality; 16% hospitalisation across both sites)

Process Outcomes (see Table 3, page 5):

• Significant improvements at the intervention facility:
  • Influenza vaccination: 71% → 95% (p = .05)
  • Physician response within 8 hours: 57% → 88% (p = .04)
  • Chest X-ray for non-hospitalised patients: 45% → 94% (p < .05)
  • Appropriate antibiotics: 63% → 81% (p < .05)
• Declines or no change observed at the control site:
  • Timely antibiotics: 70% → 17% (p < .05 decline)
  • Chest X-ray use: 77% → 18% (p < .05 decline)
• Nursing staff knowledge scores:
  • CNA knowledge improved slightly (42% → 56%), but nurse scores remained unchanged

Health System Outcomes:

• Intervention delivery was successfully achieved (e.g., full engagement with leadership, dissemination of materials, monthly check-ins)
• Implementation uptake showed high compliance with preprinted orders, antibiotic stocking, and nursing in-service attendance

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Summary Conclusion

This study shows that guideline implementation for NHAP using a multifaceted, multidisciplinary strategy is both feasible and effective in improving care processes in long-term care facilities, particularly among male-dominated veteran populations. Key gains included improvements in vaccination rates, timely and appropriate antibiotic use, and physician response times. The study highlights both the potential and the limits of change without intensive and sustained intervention across staff layers, suggesting the need for broader national application and outcome-focused trials .

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