• Daniel R Longo, Jake Young, David Mehr, Erik Lindbloom, and Lucille D Salerno.
• Department of Family and Community Medicine, University of Missouri-Columbia School of Medicine, USA. LongoD@health.missouri.edu
• J Am Med Dir Assoc. 2004 Mar 1; 5 (2 Suppl): S4-10.

Background And ObjectivesDuring a large prospective study of lower respiratory infections in nursing home residents, project staff observed that in some facilities there was consistent difficulty in obtaining timely identification of potential subjects. Starting with this motivation, we conducted a preliminary qualitative study to investigate the process of illness identification and initiating management in episodes of acute infection. We sought factors promoting timely or delayed identification and treatment of acute infections among nursing home residents.DesignQualitative study using focus groups and in-depth semi-structured interviews of residents, nurses, and physicians involved in episodes of acute-illness care in nursing home residents.SettingFour nursing homes participating in a longitudinal study of the course and outcomes of lower respiratory infection.ParticipantsFocus groups included nurses and physicians with experience in nursing home care. Interviews were conducted with those involved in six episodes of acute illness. Interviewees included four nursing home residents (two others were not cognitively intact), seven nurses, and six physicians or their staff.Data AnalysisIdentifying themes from focus group contributions and content analyses of interviews.ResultsWe identified a four-stage model describing illness identification and management. Content analysis of interview transcripts revealed 22 factors that influenced timeliness of effective care with communication problems commanding the central focus. Barriers included: (1) failure of the communication medium; (2) evening or weekend illness onset with concomitant difficulty in contacting an on-call physician; (3) clinical decision-makers who interact through intermediaries; (4) the communication of inappropriate or inaccurate information; (5) inadequate information transfer at shift changes; and (6) prior relationship between staff nurse and physician.ConclusionEffective identification and management of acute infections requires successful communication at multiple levels; however, breakdowns are common. Our model provides a framework for improving acute illness care in nursing homes, which offers important insights potentially useful in quality improvement activities in nursing homes and may facilitate further research.

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