Clinical Pathway of Loeb et al for Evaluating a Resident of a Nursing Home with a Lower Respiratory Tract Infection and Pneumonia

 

Patient selection: nursing home resident

 

A chest X-ray is performed if a patient has 2 or more of the following signs and symptoms of a lower respiratory tract infection:

(1) cough that is new or increased

(2) sputum production that is new or increased

(3) body temperature > 38°C

(4) pleuritic-type chest pain

(5) abnormal findings on physical examination of the lungs that are new or increased

 

A patient is managed in the nursing home if all of the following selection criteria are present:

(1) The patient is able to eat and drink.

(2) The pulse is <= 100 beats per minute.

(3) The respiratory rate is < 30 breaths per minute.

(4) The systolic blood pressure is adequate (see table below).

(5) Oxygen saturation is adequate (see table below).

Baseline Systolic Blood Pressure in mm Hg	Current Systolic Blood Pressure in mm Hg	Interpretation
>= 100 mm Hg	>= 90 mm Hg	adequate
>= 100 mm Hg	< 90 mm Hg	inadequate
< 100 mm Hg	(baseline) - (current) < 20	adequate
< 100 mm Hg	(baseline) - (current) >= 20	inadequate

 

 

Clinical Diagnosis	Oxygen Saturation	Interpretation
COPD	>= 90%	adequate
COPD	< 90%	inadequate
no COPD	>= 92%	adequate
no COPD	< 92%	inadequate

 

Management:

(1) The patient is treated with levofloxacin 500 mg for 10 days.

(2) If the patient can take medications by mouth, then therapy is oral. Else intravenous.

(3) The patient is admitted to a hospital if the patient fails to meet all of the selection criteria. The patient is transferred back to the nursing home when all of the selection criteria are met.

(4) The patient is initially treated in the nursing home if all of the selection criteria are met. The patient is transferred to a hospital if the patient deteriorates (no longer meets all of the selection criteria).

(5) The patient should be observed for dehydration and treated if necessary. Hypodermoclysis is recommended by the authors for patients in the nursing home who become dehydrated.