The most common cause of infectious death globally is community-acquired pneumonia (CAP), which occurs frequently and with high mortality, morbidity, and costs (Hortmann et al., 2014; Petersen et al, 2018; Zhu et al., 2018). In the United States, the total costs for pneumonia-related hospitalizations in 2014 were greater than $84 billion (Hayes et al., 2018). An important quality improvement initiative for hospitals and skilled nursing facilities (SNFs) includes decreasing unplanned inpatient pneumonia readmissions within 30 days of discharge from the index hospitalization (Hatipoglu et al., 2018; Wasfy et al., 2017). Hatipoglu et al. reported decreased payments to hospitals with high percentages of pneumonia readmissions that were implemented by the Centers for Medicare & Medicaid Services (CMS). Rates of hospital readmission within 30 days for CAP range from 15% to 20% (Hadfield & Bennett, 2018).
SNFs and hospitals provide coordinated care to reduce pneumonia readmission (Pandolfi et al., 2017). Studies in nursing home performance demonstrate that when the quality of post-acute care is improved, this care can significantly reduce hospital readmissions (Pandolfi et al., 2017).
The pneumonia care bundle was implemented in the acute care setting and the post-acute care setting (SNF, home care) with a primary objective of preventing pneumonia readmissions based on the Infectious Diseases Society of American/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults (IDSA/ATS). An interdisciplinary team referred to as the Pulmonary Integrated Care Committee (PICC) assembled to develop and implement an evidence-based pneumonia care bundle. The detailed measures of the pneumonia care bundle include risk stratification according to the IDSA/ATS 2019 guidelines for patients admitted through the emergency department (ED). Additional measures include diagnostic tests such as completion of a chest radiograph in the emergency department (ED) identifying an obvious infiltrate, the first antibiotic dosing in the ED was administered within 4 hr of admission, and antibiotic therapy for CAP should be treated for a minimum of 5 days but may require longer treatment in the SNF if the initial treatment was not effective (Mandell et al., 2007).
Two hospitals in Northwest New Jersey identified risk factors for pneumonia readmission, and these included older age, longer length of stay, comorbidities including cancer, coronary heart disease, chronic heart failure, chronic kidney disease, anticoagulation therapy with warfarin (Coumadin), anemia, hypoalbuminemia, and prior admission to the hospital (Hatipoglu et al., 2018).
Background
In this retrospective cohort study, an evidence-based pneumonia care bundle was implemented at 11 SNFs with a primary outcome to reduce 30-day hospital readmissions. Inclusion criteria were patients hospitalized, aged 18 years and older, carried traditional Medicare insurance, diagnosed with pneumonia, and discharged from an acute care hospital to an SNF. Exclusion criteria included patients unable to participate in patient education for pneumonia, diagnosed with severe sepsis, and discharged against medical advice.
The Process and Interventions
The post-acute care coordinator (PACC) of the Case Management Department met with the PICC team to discuss the evidence-based practices for pneumonia that were required to improve patient outcomes and subsequently reducing readmissions. Our health care system collaborates with several SNFs to decrease 30-day hospital readmissions. It was hypothesized that to decrease readmissions from the SNFs, we needed to address the quality of care provided by the SNFs by using a two-step approach:
1. Education was provided by the PACC to the nursing staff at the SNF. The topics included the anatomy and physiology of the respiratory system; pathophysiology of the pneumonia; complications of tube feeds; the pneumonia care bundle and the pneumonia action plan; antimicrobials used to treat pneumonia; and nursing care guidelines to monitor for changes in status. We also included how to use the nomogram information packet with incentive spirometers (ISs) based on the patient's age and height in inches.
2. The PACC completed weekly follow-up visits to the facility to meet with the primary care nurse/unit manager. At this meeting, there was a review of the status of the patient, medication reconciliation, and confirmation that guidelines and bundle elements were being followed. Continuing education was provided to the staff as needed.
The PACC scheduled weekly visits to facilities that had received residents with a diagnosis of pneumonia from the system hospitals. To prepare for the first meeting, the PACC reviewed each individual resident's history and physical, discharge summary, and the after-visit summary. At the first SNF visit, there was a meeting with the primary nurse/unit manager caring for the resident with pneumonia. Elements of the pneumonia bundle were reviewed to ensure that the bundle was adequately implemented, and the Pneumonia Patient Education Book was used to educate the residents, which included the importance of the pneumonia action plan, aspiration precautions, and proper oral care. A comparison was completed reviewing the most accurate list of medications that the resident was taking in the SNF to the hospital discharge medication list, including the name of the drug, dosage, frequency, and route. When inhalers were ordered, nurses were educated to assess whether the resident could complete a proper 10-s breath hold. When residents were unable to complete a proper inhaler technique, nurses were educated to request that the provider change the inhaler to nebulized medications. A review of current laboratory diagnostics occurred for abnormalities, and nurses were educated to inform the provider.
During the initial visit, the PACC would review aspiration pneumonia cases to determine whether aspiration precautions were ordered. When aspiration precautions were ordered, a meeting was held with the speech therapist to ensure that proper swallow techniques and aggressive oral care were ordered. IS use was continued in the SNF to provide adequate lung expansion, and each resident had their personal best goal calculated by using the IS nomogram. The IS personal best goal was calculated on the basis of the resident's age and height in inches. Dysphagia diets were ordered for residents diagnosed with aspiration pneumonia, and drinks were thickened. Oral care included toothbrushing to remove dental plaque, swabbing to remove oral debris and secretions, and moisturizing to hydrate the lips and oral cavity. In addition, there would be confirmation that all residents had a primary care provider (PCP), or pulmonologist follow-up appointment arranged within 7 days of admission.
Residents admitted to the SNF with a new percutaneous endoscopic gastrostomy (PEG) feeding tube due to dysphagia were carefully reviewed. The PACC collaborated with the registered nurse to verify the tube feeding formula, calorie count, and rate of flow. When orders were received for "nothing by mouth" (NPO), the PACC reviewed the route of medication administration to verify that all medications were being administered via the PEG tube. Medications that could not be crushed were substituted by medications that could be safely crushed. Nurses were educated and provided strategies on the signs and symptoms of aspiration.
During the second weekly visit, a clinical review of the patient's vital signs, breath sounds, and recent laboratory results would take place. The PACC confirmed the discharge dates, completion of the pneumonia action plan, and the results of pulmonologist follow-up appointment. When indicated, additional follow-up provider appointments were arranged to address comorbidities including diabetes mellitus, congestive heart failure, and end-stage renal disease.
During the third-week PACC visit and extending up to the day of discharge, each resident would be evaluated for respiratory stability and comorbidity stability. A review of the discharge plans included the need for a referral to home care. Patient and family education was completed using the Pneumonia Patient Education Book and confirmed it will accompany the resident at the time of discharge. After SNF discharge, the PACC ensured that home care visits were initiated and home medication reconciliation was accurate. There was also confirmation that the Pneumonia Care Book and IS were in use in the resident's home. There was validation with the visiting nurses that residents who required home tube feedings or dysphagia diets were in place as part of the plan of care. In addition, the family caregivers were given education on the importance of home dysphagia diets or home tube feedings.
Results
Ninety-nine patients were enrolled in the preintervention cohort and 34 patients were enrolled in the postintervention cohort. Thirty-day readmission rates were lower in the postintervention cohort (24.2% vs. 17.7%). This reduction in readmission rates was clinically significant, demonstrating a 27% reduction for all patients discharged from the hospital to an SNF with pneumonia (see Figure 1).
Readmissions following an index hospitalization for pneumonia are frequent, and studies demonstrate approximately 16% of patients are readmitted within 30 days (Hatipoglu et al., 2018). The rate of 30-day readmission in the current study is higher in the preintervention cohort than in the postintervention group (24.2% vs. 17.7%). This reduction in readmission rates was clinically significant, demonstrating a 27% reduction for all patients discharged from the hospital to an SNF with pneumonia. The readmission rate is higher in this study than in the national average and may be due to the complexity of patients discharged from the hospital to an SNF. Complex risk factors in this study included large numbers of socioeconomically challenged patients, current smokers, patients diagnosed with both dementia and aspiration pneumonia, frail elderly patients, and large numbers of patients with pneumonia complications including patients with cancer, heart failure, diabetes mellitus, empyema, and end-stage-renal disease.
Limitations
We acknowledge that the study has limitations. First, the study was a retrospective cohort study comparing patients in the preintervention cohort who received pneumonia standard of care versus patients in the postintervention cohort who received a PACC evidence-based pneumonia care bundle. Second, readmissions outside our health care system may not have been captured. Third, the sample size is small and may not be generalizable to a larger SNF population. Fourth, a large randomized controlled trial (RCT) was not conducted, and it is possible that the results on which we based our interventions will be superseded by larger RCTs.
Improvement of the limitations includes implementation of our pneumonia care bundle at SNFs nationally and globally. Limitations may be improved by conducting national and global RCTs studying the effects of an evidence-based pneumonia care bundle at SNFs.
Conclusion
Although interventions to reduce 30-day readmissions for pneumonia are few, this study focused on an evidence-based pneumonia care bundle directed at patients who are at high risk for a hospital readmission from an SNF (Adamuz et al., 2015; Borzecki et al., 2015; McLeod-Sordjan et al., 2011). The pneumonia care bundle is an evidence-based intervention aimed at preventing readmissions and is affordable, not complicated to use, and easy to replicate in an SNF and has proved beneficial in this study.
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