When nursing home residents are hospitalized for pneumonia or other lower-respiratory-tract infections, they incur higher costs and often suffer a progressive decline in health. To determine if a clinical treatment pathway, or algorithm, managed by nurses could be effective in treating such residents and thereby reducing the rate of hospitalizations, Canadian researchers randomized 22 nursing homes into two groups. The 327 residents in the intervention group were treated with the clinical pathway, which included treating dehydration, monitoring oxygenation, and administering levofloxacin for 10 days. The usual-care control group included 353 residents for whom the patients' physicians made treatment decisions in concert with the nurses on staff.

Facilities that implemented the clinical pathway had hospital admission rates of 8% for residents with lower-respiratory-tract infections and pneumonia, compared with 20% in nursing homes providing usual care; for pneumonia alone, the hospital admission rates were 9% and 29%, respectively. Between the two groups there were no significant differences in mortality rate or in the number or severity of adverse effects, functional status, health-related quality of life, and rates of ED visits, secondary infections, and falls.

The clinical pathway cost an average of $165 per resident, $87 more than the cost of usual care per resident. But hospitalization costs averaged $1,018 per resident in the pathway nursing homes, compared with $2,122 per resident in the usual-care homes.

The researchers estimate that lowering the rates of hospitalization for nursing home residents with lower-respiratory-tract infections through implementation of the clinical pathway could save $70 million annually in Canada and $831 million annually in the United States. However, Canada has a single-payer health system and the authors acknowledge that the multiple-payer system could be a barrier to implementation in the United States.

Fran Mennick, BSN, RN