Introduction

This quality standard covers adults (18 years and older) with a suspected or confirmed diagnosis of community‑acquired pneumonia. For more information see the pneumonia topic overview.

Why this quality standard is needed

Pneumonia is an infection of the lung tissue. When a person has pneumonia the air sacs in their lungs become filled with microorganisms, fluid and inflammatory cells and their lungs are not able to work properly. Diagnosis of pneumonia is based on symptoms and signs of an acute lower respiratory tract infection, and can be confirmed by a chest X‑ray showing new shadowing that is not due to any other cause (such as pulmonary oedema or infarction). The NICE guideline on pneumonia classifies pneumonia depending on the source of the infection as community‑acquired or hospital‑acquired, which need different management strategies.

Every year between 0.5% and 1% of adults in the UK will have community‑acquired pneumonia. It is diagnosed in 5–12% of adults who present to GPs with symptoms of lower respiratory tract infection, and 22–42% of these are admitted to hospital, where the mortality rate is between 5% and 14%. Between 1.2% and 10% of adults admitted to hospital with community‑acquired pneumonia are managed in an intensive care unit, and for these patients the risk of dying is over 30%. More than half of pneumonia‑related deaths occur in people older than 84 years.

At any time, 1.5% of hospital patients in England have a hospital‑acquired respiratory infection, more than half of which are hospital‑acquired pneumonia and are not associated with intubation. Hospital‑acquired pneumonia is estimated to increase a hospital stay by about 8 days and has a reported mortality rate ranging from 30–70%. There are variations in clinical management and outcomes across the UK.

The quality standard is expected to contribute to improvements in the following outcomes:

  • mortality

  • hospital admission and re‑admission

  • length of hospital stay

  • health‑related quality of life

  • inappropriate antibiotic use.

How this quality standard supports delivery of outcome frameworks

NICE quality standards are a concise set of prioritised statements designed to drive measurable improvements in the 3 dimensions of quality – patient safety, patient experience and clinical effectiveness – for a particular area of health or care. They are derived from high‑quality guidance, such as that from NICE or other sources accredited by NICE. This quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following 2 outcomes frameworks published by the Department of Health:

Tables 1–2 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.

Table 1 NHS Outcomes Framework 2015–16

Domain

Overarching indicators and improvement areas

1 Preventing people from dying prematurely

Overarching indicators

1a Potential Years of Life Lost (PYLL) from causes considered amenable to healthcare

i Adults

1b Life expectancy at 75

i Males ii Females

Improvement areas

Reducing premature mortality from the major causes of death

1.2 Under 75 mortality rate from respiratory disease*

3 Helping people to recover from episodes of ill health or following injury

Overarching indicators

3a Emergency admissions for acute conditions that should not usually require hospital admission

3b Emergency readmissions within 30 days of discharge from hospital*

4 Ensuring that people have a positive experience of care

Overarching indicator

4a Patient experience of primary care

i GP services

ii GP out‑of‑hours services

4b Patient experience of hospital care

4c Friends and family test

4d Patient experience characterised as poor or worse

ii Hospital care

Improvement areas

Improving people's experience of outpatient care

4.1 Patient experience of outpatient services

Improving hospitals' responsiveness to personal needs

4.2 Responsiveness to inpatients' personal needs

Improving people's experience of accident and emergency services

4.3 Patient experience of A&E services

Improving the experience of care for people at the end of their lives

4.6 Bereaved carers' views on the quality of care in the last 3 months of life

5 Treating and caring for people in a safe environment and protecting them from avoidable harm

Overarching indicators

5a Deaths attributable to problems in healthcare

5b Severe harm attributable to problems in healthcare

Improvement areas

Reducing the incidence of avoidable harm

5.2 Incidence of healthcare associated infection (HCAI)

  • ii C. difficile

Improving the culture of safety reporting

5.6 Patient safety incidents reported

Alignment with Adult Social Care Outcomes Framework

* Indicator is shared

** Indicator is complementary

Indicators in italics in development

Table 2 Public health outcomes framework for England, 2013–16

Domain

Objectives and indicators

4 Healthcare public health and preventing premature mortality

Objective

Reduced numbers of people living with preventable ill health and people dying prematurely, while reducing the gap between communities

Indicators

4.3 Mortality rate from causes considered preventable**

4.7 Mortality from respiratory diseases

4.11 Emergency readmissions within 30 days of discharge from hospital*

4.13 Health‑related quality of life for older people

4.15 Excess winter deaths

Alignment across the health and social care system

* Indicator is shared

** Indicator is complementary

Patient experience and safety issues

Ensuring that care is safe and that people have a positive experience of care is vital in a high‑quality service. It is important to consider these factors when planning and delivering services relevant to pneumonia. In particular, it will be important to ensure that adults with pneumonia have an understanding of how long it may take to recover as well as when they may need to seek further advice.

NICE has developed guidance and an associated quality standard on patient experience in adult NHS services (see the NICE Pathway on patient experience in adult NHS services), which should be considered alongside this quality standard. They specify that people receiving care should be treated with dignity, have opportunities to discuss their preferences, and be supported to understand their options and make fully informed decisions. They also cover the provision of information to patients and service users. Quality statements on these aspects of patient experience are not usually included in topic‑specific quality standards. However, recommendations in the development sources for quality standards that affect patient experience and are specific to the topic are considered during quality statement development.

Coordinated services

The quality standard for pneumonia specifies that services should be commissioned from and coordinated across all relevant agencies encompassing the whole pneumonia care pathway. A person‑centred, integrated approach to providing services is fundamental to delivering high‑quality care to adults with pneumonia acquired in community settings.

The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning and delivering services, as part of a general duty to secure continuous improvement in quality. Commissioners and providers of health and social care should refer to the library of NICE quality standards when designing high‑quality services. Other quality standards that should also be considered when choosing, commissioning or providing a high‑quality pneumonia service are listed in related quality standards.

Training and competencies

The quality standard should be read in the context of national and local guidelines on training and competencies. All healthcare professionals involved in assessing, caring for and treating adults with pneumonia should have sufficient and appropriate training and competencies to deliver the actions and interventions described in the quality standard. Quality statements on staff training and competency are not usually included in quality standards. However, recommendations in the development sources on specific types of training for the topic that exceed standard professional training are considered during quality statement development.

Role of families and carers

Quality standards recognise the important role families and carers have in supporting adults with pneumonia acquired in community settings. If appropriate, healthcare professionals should ensure that family members and carers are involved in the decision‑making process about investigations, treatment and care.