The aim of this study was to identify gaps between current clinical practice and EBG recommendations regarding diagnostic procedures, medical treatment and general management for older patients with CAP. We identified a few, but potentially serious gaps in diagnostic procedures and medical treatment, as well as in general management, all of them with possible impact on patient outcomes and safety.
Diagnostic procedures and medical treatment
Among diagnostic procedure recommendations, the severity assessment score CURB-65 was rarely used within the units included in this study. This result is consistent with previous national and international research findings [
18,
28‐
30]. Initial assessment of illness severity is considered to be one of the most important steps in the management of older patients admitted with CAP [
7,
11‐
14]. It supports HPs in determining patient needs at admission, site of care, the extent of diagnostic testing and in choosing the appropriate antibiotic treatment, all of which are independent factors with impact on CAP patient morbidity and mortality [
7,
11‐
14]. Our results and previous studies indicate that CURB-65 is not routine practice in hospital settings and tailored implementation strategies are needed [
22] to achieve higher adherence rates for the benefit of patient safety and the health economy.
Among medical treatment procedures, the initial choice of antibiotics was the intervention that was least frequently carried out according to recommendations. Presumably, this is a consequence of the low prevalence of severity assessment, as the initial choice of antibiotic treatment should be guided by the CURB-65 score [
7,
11‐
14]. Appropriate antibiotic prescription in hospitals ensures effective treatment of patients and administration of appropriate antibiotics within 4–8 h is associated with 5–43% relative reduction in mortality [
31,
32]. Inappropriate antibiotic therapy, on the other hand, is an independent predictor of in-hospital and 30-day mortality and associated with morbidity and increased treatment costs [
31,
33‐
35]. Regrettably, inappropriate antibiotic treatment is common, both when it concerns the initial choice of AB [
36,
37] and treatment targeted the identified pathogen [
33]. A Cochrane review [
38] finds strong evidence for the effect on compliance of interventions that support physicians in prescribing the appropriate treatment (e.g. procedural instructions, feedback and stewardship). Further effects were reduced duration of antibiotic treatment by 1.95 days (95% CI 2.22 to 1.67) and length of stay by 1.12 days (95% CI 0.70 to 1.54).
Timely switch from intravenous to oral antibiotic treatment was seen in most cases in our study. Early switch of antibiotic treatment not later than the third day may reduce the iatrogenic events and LOS by 3.4 days [
39,
40]. Importantly, a quarter of our sample were not switched to oral treatment in time despite clinical and haemodynamical stability as recommended in EBG [
7,
11‐
14], with possible consequences for patient safety and economy [
39]. Therefore, there is also a need to identify barriers to early switching and to develop a tailored strategy for the implementation of an intervention that facilitates timely switching to oral treatment.
More than a quarter of the patients in our study did not respond to treatment within the expected time frame, and a systematic diagnostic approach for non-responding patients was limited. It is common to find patients not responding to treatment, and mortality rates for those patients are reported as high as 49% [
13]. Therefore, it is strongly recommended to reassess non-responding patients’ treatment and to perform multiple relevant diagnostic tests to determine specific respiratory pathogens, in order to permit prescription of appropriate antibiotic treatment [
7,
11‐
14]. According to Arancibia et al. [
41] a systematic diagnostic approach by invasive, non-invasive, and imaging procedures can lead to a specific diagnosis in 73% of cases. Hence, a systematic and evidence-based approach to avoid treatment failure and reduce the rate of in-hospital mortality seems warranted.
General management
General management i.e. nursing care interventions, performed by nurses in our study, are vital for patients with CAP as they are reported to have reduced morbidity, mortality, LOS and readmission rates [
15,
42‐
51].
The only nursing care intervention that was performed systematically in our study was oxygen therapy, whereas sputum mobilisation by PEP and oral care were carried out less frequently. Previous studies have identified that PEP treatment can reduce fever duration and length of hospital stay [
42,
48] and oral care in critically ill patients is associated with 18 to 24% of reduction in the odds of developing ventilator-associated pneumonia [
51], while low adherence to oral care has consequences such as pain, malnutrition, readmissions, increased healthcare costs and mortality [
10,
46,
51]. Therefore, special attention should be paid to sputum mobilisation and oral care to achieve better adherence among HPs, in order to deliver effective and safe treatment for patients with CAP.
Despite plans for fluid therapy made for most patients in our study, adherence to planned interventions were rare and unsystematic, which can put the patient at risk of renal and electrolyte complications. According to Guppy et al. [
52] the incidence of hyponatremia is common for patients with infections of the lower respiratory tract and 10.5% of CAP patients have been identified as developing hyponatremia during hospitalization. Those results indicate the need to focus on fluid therapy when designing a strategy to implement evidence-based practice for patients with CAP.
The majority of the patients in our study were at nutritional risk but, as nutrition support plans were either lacking, or at best insufficient (e.g. missing calculation of individual needs for energy and protein for all 30 patients), the nurses could not assess the sufficiency of the patients’ intake nor could the researchers assess HPs’ adherence to recommendations for nutrition support. Therefore, adherence to nutrition support needs to be determined with further research.
In our study, more than half of the patients were mobilised 20 min or more. Noting that EBG strongly recommend 20 min mobilisation within 24 h of hospitalisation and increase of mobilisation each subsequent day, our results indicate that approximately a quarter of the patients were mobilised less than recommended. Even though mobilisation plans were frequently developed, activities according to mobilisation plans were less frequently performed. Those results are consistent with other studies reporting that older patients with CAP may be at risk of functional loss during hospitalisation and after discharge, due to insufficient mobilisation [
20,
53]. Considering that regular mobilisation reduces functional decline, mobilisation should be encouraged for older patients with CAP during hospitalisation [
54]. Moreover, studies of CAP demonstrate that early mobilisation is safe and effective in reducing length of hospital stay [
45,
55].
To deliver effective and targeted nursing care interventions, a systematic assessment of patient individual needs and development of an individual nursing care plan is essential [
7‐
15]. In our study, nursing care plans were found to be scarce and unsystematically developed (e.g. missing data on patient status, developed only partly, intervention or duration of the intervention not described according to EBG recommendations). This supported previous finding by Lindhardt et al. [
18] who found care planning for patients with CAP to be rare and unsystematic and nursing documentation insufficient. Jones et al. [
47] identified also nursing care planning to be among the top five most frequently incomplete activities in nursing practice. On the other hand, an observational study by De Marinis et al. [
23] has reported that only 40% of nursing activities are consistent with the documentation as nurses perform more activities than they report. This result is supported by findings from the recent systematic review [
56] that found nursing care planning to be more often missed than performance of nursing care. The level of missed nursing care associated with adverse patient outcomes is high, with an overall estimate of 88% in acute hospitals in Europe [
56]. The association between nursing care planning and the level of interventions performed was not under investigation in our study but deserves more specific attention in future studies.
The lack of systematic care planning and management of described interventions constitutes a threat to patient safety. Nevertheless, our findings are not breaking news as the phenomenon of
missing care, defined as any aspects of care that is omitted or delayed, in part or in whole [
56], is a comprehensive problem nationally and internationally with a prevalence of 55–98% in acute care hospitals [
47,
49,
50]. Seemingly, among all the EBG recommendations in our study, nurses had more difficulties adhering to EBG than the physicians. Due to the scope of the study, the cause of the low adherence is unknown and needs further investigation in future studies. Other studies have identified staffing, time scarcity, resources, inadequate support from peers, professional behaviour, knowledge and culture as some of the factors that could influence HPs’ adherence to EBG [
34,
56‐
58]. Further, the insufficient and inadequate description of nursing interventions in the EBG for treatment and care of CAP could also be considered a barrier to nurses’ adherence to EBG recommendations. While national and international EBG for CAP thoroughly review diagnostic tools and choice of antibiotic treatment, they do not emphasise the importance of nursing care interventions and the consequences of missed care. Considering the impact of nursing interventions for patient recovery and safety [
59,
60], the absence of description of nursing interventions in EBG constitutes a threat to successful patient outcome. Therefore, the revision of the EBG should be considered. However, our results indicate that even if diagnostic procedures and medical treatment are well described in the EBG, only a fraction of these guidelines have been implemented in clinical practice. This could indicate that even a thorough description of nursing interventions in the EBG may not increase the adherence rate. Instead, according to implementation researchers [
21,
22] factors influencing HPs adherence to EBG should be focused on in order to promote the successful uptake of research findings into routine practice and improve the quality and effectiveness of treatment and care. Implementation science emphasizes that factors influencing HPs’ adherence to EBG can be linked to both individual, team and organizational level and are related to the context where the treatment and care is performed [
22,
61]. The context is recognized as a core factor that influences implementation [
22,
62]; thus, it is important to identify contextual barriers hindering, and facilitators supporting HPs in performing evidence-base practice. This is considered a fundamental criterion for successful implementation as this knowledge is crucial for the development of tailored and context-oriented implementation strategies targeting the problem areas [
21,
22,
63].
Methodological considerations
The strength of this study was the triangulation of research methods [
64] where observations, interviews and data from patient records allowed us to reveal different perspectives of a research question and helped us to achieve better understanding of the real-life management of older patients with CAP in a hospital setting. Particularly, individual ad hoc interviews were helpful to complete the data collection, as interviews revealed uncertainties that were not possible to clarify by observations or by audits, e.g. clarification of whether assessment of CURB-65 had taken place, or whether oral care had been carried out. We also acknowledge the limitation that all data were collected by a single researcher. Observations were carried out only by the first author as the presence of several observers could have affected the natural context for HPs and intimidated both them and the patients. The first author is a registered nurse with many years of professional experience, including the care of CAP patients and had a pre-understanding of the context that was required to analyse and collect data in a complex setting by multiple methods. However, this inside perspective and preunderstanding can be perceived both as a methodological strength and limitation. To enhance credibility, all authors were involved in reflections and discussions throughout the data collection period, analysis and evaluation of the project to challenge the first author’s preunderstanding, choices and interpretations.
To identify HPs’ adherence to EBG recommendations, the researcher had to make her own assessment of each patient’s condition and needs. The conclusion reached in the assessment of the patient may therefore differ from that of the HPs. However, researcher’s assessment of patient conditions and needs was guided by the EBG and as such are expected to be followed by the HPs. To increase the credibility, the last author rechecked the first author’s assessment of patient individual needs according to EBG criteria and patient’s clinical data. Furthermore, after transformation of qualitative data to quantitative data, all numerical data were rechecked according to the content in transcribed text. After entering data into SPSS, all data were rechecked three times before performance of any statistics. It is also worth noting that the study was carried out in a single hospital and the sample size for participating patients was small; hence, the transferability of the findings may be limited as the study may be context-specific.