Life In The Slower Lane

Here is the PICO analysis for the article:

Full Article Title:

Antibiotic Use, Hospital Admissions, and Mortality Before and After Implementing Guidelines for Nursing Home–Acquired Pneumonia

Authors: Naughton BJ, Mylotte JM, Ramadan F, et al.

Journal: Journal of the American Geriatrics Society (JAGS) (2001); 49(8):1020–1024

DOI: 10.1046/j.1532-5415.2001.49203.x

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✅ PICO Analysis

Type of Study:

Randomised controlled trial (cluster design, 10 SNFs)

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P – Population

• Setting:10 skilled nursing facilities (SNFs) in the Buffalo, New York, metropolitan area
• Participants:
  • 350 episodes of nursing home–acquired pneumonia (NHAP) in residents
  • 226 preintervention episodes (baseline)
  • 116 postintervention episodes (after guideline implementation)
  • Inclusion required radiologic evidence of pneumonia plus major/minor symptoms
  • Excluded if prior pneumonia episode occurred ❤ months earlier
• Resident Characteristics:
  • High comorbidity, functional dependence, and mortality risk typical of SNF residents

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I – Intervention

Implementation of Antibiotic Guidelines for NHAP, developed via local practice data and physician consensus:

• Physician-only intervention (5 SNFs):
  • Small-group meetings, guideline discussion
  • Distribution of laminated pocket cards with recommended oral and parenteral antibiotic protocols
• Multidisciplinary intervention (5 SNFs):
  • Same physician intervention plus:
    • 1-hour nurse education sessions (for all shifts)
    • Problem-solving discussions to identify barriers
    • Laminated posters with guidelines displayed
• Guidelines included:
  • Recommendations for initial antibiotic route (oral vs parenteral)
  • Duration of therapy
  • Criteria to switch from parenteral to oral therapy

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C – Comparison

• Pre/post comparison of all facilities
• Between-group comparison of physician-only vs multidisciplinary implementation arms
• Adherence to guidelines pre and post implementation
• Outcomes assessed: adherence to antibiotic guidelines, hospitalisation, mortality

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O – Outcomes

Person-Centred Outcomes:

• 30-day Mortality:
  • Preintervention:
    • PA group: 37.8%
    • OA group: 6.1%
  • Postintervention:
    • PA group: 23.8%
    • OA group: 11.5%
  • No statistically significant reduction in mortality postintervention overall (23.9% → 18.1%; p = .27) 

Process Outcomes:

• Guideline-concordant antibiotic prescribing:
  • Overall adherence improved from 60.1% to 67.2%
  • Parenteral antibiotic (PA) adherence:
    • Increased from 62.2% to 73.4% (p = .02)
    • Greatest increase in the multidisciplinary group (50% → 81.8%, p = .06)
  • Oral antibiotic (OA) adherence:
    • No significant change (57.6% → 59.6%) 
• Hospitalisation:
  • No change in hospitalisation rates (39.8% pre vs 36.4% post, p = .57)
  • Guideline implementation did not influence hospital admission decisions

System-Level Outcomes:

• Variability in PA prescribing reduced
• Hospitalisation remained unaffected due to:
  • Reimbursement incentives favouring hospital transfers
  • Lack of explicit guidance in the implemented guideline regarding hospitalisation

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Summary Conclusion

This study showed that a structured implementation of antibiotic guidelines for NHAP modestly improved guideline-concordant prescribing—especially use of parenteral antibiotics when indicated—but did not affect hospitalisation rates or overall mortality. The multidisciplinary approach (involving nurses) led to better adherence than physician-only strategies, but the improvement did not reach statistical significance. The findings underscore that while prescribing behaviours can be changed, other factors—like reimbursement structures and lack of hospitalisation guidance—limit broader system impacts. A future strategy combining clinical pathways and financial alignment may be more effective .

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