Re-hospitalizations – Pneumonia

Angie SzumlinskiUncategorized

Pneumonia is the leading cause of mortality, morbidity and transfers to acute care facilities among residents of nursing homes.  A study performed at Brown University suggests that there is growing evidence that the transfer of residents with Nursing Home Acquired Pneumonia (NHAP) results in little to no improvement in overall mortality or morbidity when compared with residents treated in the nursing home.  Nursing home residents admitted to hospitals may be at greater risk for functional decline, delirium and pressure ulcer formation following hospitalization.

There is growing evidence to suggest that hospitalization for residents with NHAP is not required and may result in increased cost, morbidity and mortality.  To date, studies show that residents may benefit from hospitalization if their respiratory rate is over 40.  Otherwise if appropriate treatment can be initiated expeditiously in the nursing home, resident mortality and morbidity may decrease.  Numerous barriers to treating acutely ill residents in the nursing home exist, including:

  • Difficulty in obtaining antibiotics quickly –
    • What is your process? 
    • Do you have a back up box with appropriate antibiotics readily available? 
    • Do you have licensed staff trained to initiate an IV?
  • Inadequate staffing –
    • We hate that term right? 
    • What does your staffing look like? 
    • Do you have enough licensed staff to care for critically ill residents?
  • Poor documentation of a resident’s wishes for hospitalization –
    • What is your process for obtaining this information upon admission? 
    • Are the advance directives clear and accurate for each resident? 
    • When was the last time you updated/verified them?

Wow, lots of words but interesting outcomes.  As caregivers we are all aware of the challenges of caring for the frail elderly.  What are we doing to enhance our programs and avoid the necessity of re-hospitalization?  What steps are we taking to prevent the spread of infection during the highest illness season of the year?  Remember, it is totally okay to limit visitation if a visitor is with active illness, cough, fever or respiratory symptoms.  It is a standard to post a notice on entranceways that state, “if you have active symptoms of infection please come back to visit when you are feeling better.  Our residents are frail and exposure to illness can result in hospitalizations”. 

McGreer Criteria for infection control has been recognized as a standard since 1991.  In October 2012 the “Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGreer Criteria” was released. This criterion was determined by an expert consensus panel based on a structured review of research and evidenced-based literature.  The criteria that define infections were systematically reviewed and have resulted in changes of the original consensus definitions also known as the McGreer Criteria.  

Some changes in the criteria are the addition of definitions of constitutional criteria (Table 2.) in residents of long term care facilities. The decision to use “constitutional care” was made to maintain consistency across different infection guidelines.


This Constitutional Criteria includes:


  • Fever
  • Leukocytosis
  • Acute change in mental status from baseline (CAM criteria also found in MDS 3.0)
  • Acute functional decline in activities of daily living (ADLs)
    • A new 3-point increase in total activities of daily living (ADL) score (range, 0-28) from baseline, based on the following 7 ADL items, each scored from 0 (independent) to 4 (total dependence): Bed mobility, Transfer, Locomotion within LTCF, Dressing, Toilet use, Personal hygiene, Eating

The definition of fever was changed from a temperature greater than 100.4 degrees Fahrenheit and is consistent with the 2008 Infectious Disease of America (IDSA) guideline for evaluating fever and infection in older adults residing in long term care facilities (LTCFs):


  1. A single oral temperature greater than 37.8°C (100°F); or
  2. Repeated oral temperatures greater than 37.2°C (99°F) or rectal temperatures greater than 37.5°C (99.5°F); or
  3. A single temperature greater than 1.1°C (2°F) over baseline from any site.

The following have been made to the criteria for respiratory tract infection: 


Respiratory Tract Infection 

When reviewing for potential respiratory infection, it is important that other conditions are ruled out such as congestive heart failure, pulmonary embolism, atelectasis, etc..

  • Removal of seasonal restrictions for influenza-like illness
  • Pneumonia and lower respiratory tract infections- at least one respiratory symptom, and at least one constitutional criteria along with radiographic findings to define pneumonia. This should facilitate the surveillance into three categories including radiography results, respiratory signs or symptoms and constitutional criteria.
  • For lower respiratory tract infection oxygen saturation of <94% or <3% from baseline was added.  

Remember, nothing replaces a thorough assessment and ongoing monitoring of any signs or symptoms of a change in condition.  In order to accurately identify a change however it is critical that we obtain a complete respiratory baseline during admission including lung sounds, observation of breathing and color as well as oxygen saturation ratings.  

Stay healthy, stay safe and remember only you can prevent the spread of infections with resulting hospitalizations.  For additional information please contact your HealthCap Risk Manager.

Source: Infection Control and Hospital Epidemiology Vol.33, No.10(October2012), pp. 965-977

Source:  Division of Geriatrics and Department of Medicine and Community Health, Brown University, Providence, RI, USA.

Republished in:  J Am Med Dir Assoc. 2006 Mar;7(3 Suppl):S74-80, 73.