PEL/VIP Pneumonia Protocol Program

Recognition of Pneumonia Risk and Recommended Treatment in a Skilled Nursing Facility

OBJECTIVES

  • Brief discussion of Skilled Nursing Facility data regarding the incidence of pneumonia
    • Discussion of risk factors that should be recognized
  • These will be found in Pneumonia Risk Scoring Tool
  • Review of assessment criteria to assess risk of pneumonia
    • This will be found in Pneumonia Risk Scoring Tool
  • Review of Facility Staff Workflow Process after patient is scored and placed into Pneumonia Protocol (either Low or High Probability)
  • Review of Guidelines for Hospital Admission for patients with suspected pneumonia
    • These are strictly guidelines
  • Review of forms used in Protocol
    • Pneumonia Risk Scoring Tool
    • Workflow Algorithms (Low/High Probability)
    • Additional RT Forms that will be used
  • Review of Outcomes Management

Pneumonia

  • The incidence of pneumonia is higher in Nursing Homes than in any other setting.
    • A practical definition of pneumonia is a new infiltrate on chest X-ray with at least two clinical signs of:
      • new/increased cough or sputum production
      • fever >38 C
      • pleuritic chest pain
      • new relevant chest exam findings
      • dyspnea/tachypnea
      • worsened mental/functional status

 

Know Pneumonia: The reality versus the Evidence of Diagnosis & Treatment; Levenson S, Crecelius C, Caring for the Ages, August 2003; Vol.4, No. 8, p.14

Pneumonia

  • Historically, 2/3 to 3/4 of NH residents with pneumonia are treated without hospitalization.
  • There is an increasing need to develop an evidence-based strategy to:
    • Recognize risk factors
    • Carefully assess clinical signs and symptoms
    • Initiate appropriate general practices and treatment modalities upon admission of residents.

 

Breathe Easy: Managing Respiratory Infections in LTC Facilities requires well-defined policies, effective surveillance & strong communication; Kaldy J, Caring for the Ages, December 2003

This protocol will discuss risk factors, early and frequent patient assessment and available treatment modalities.

Assess Risk Factors.

If 2 or more are identified then perform Clinical Scoring Assessment part of the Pneumonia Risk Scoring Tool Worksheet

PNEUMONIA RISK FACTORS

(Assessing these Risk Factors are the first part of the Pneumonia Risk Scoring Tool Worksheet)
  • Conditions favoring reflux
  • Dysphagia
  • Swallowing difficulties and/or history of aspiration
  • Presence of a Gastric or Nasogastric Tube
  • History of COPD
  • Extremes of age
  • Poor oral hygiene
  • Recent history of prolonged use of ventilator support
  • Presence of tracheostomy tube
  • Swallowing difficulties and/or
  • history of aspiration
  • Neurological impairment
  • Co-morbidities especially renal disease
  • Poor functional status
  • Immunosuppression
  • Conditions that predispose to bacteremia (indwelling catheters, pressure ulcers)
  • Immobility
  • Supine position
  • Use of sedating medications
  • Malnutrition
  • Recent thoracic/abdominal surgery

Clinical Assessment Criteria to Assess Probability for Risk of Pneumonia

(This is part of the Pneumonia Risk Scoring Tool Worksheet)

  • Laboratory testing may include White Blood Cell (WBC) count. Look for WBC > 10,000 per mm3
  • Baseline vital signs to include Respiratory Rate (RR). Look for RR > 30
  • Baseline vital signs to include Temperature. Look for Temp > 38 C
  • Baseline vital signs to include Heart Rate (HR). Look for HR > 110

Clinical Assessment Criteria to Assess Probability for Risk of Pneumonia

(This is part of the Pneumonia Risk Scoring Tool Worksheet)

  • Baseline vital signs to include Breath Sounds (BrS). Look for presence of wheezes and/or moist crackles. (If moist crackles are bilateral, think CHF)
  • Baseline resident assessment to include cognition assessment. Look for presence of decreased alertness, somnolence or acute confusion
  • Presence of coughing with new or increased sputum production
*Scoring system for projecting probability of Pneumonia* (2)

Review the Pneumonia Risk

Scoring Tool Worksheet

This will be filled out completely for patients who have 2 or more risk factors present.
Patient will be placed into a Low Risk Probability or High Risk Probability category.
(Each category has it’s own workflow algorithm)

IMPORTANT GENERAL PNEUMONIA RISK INTERVENTION STRATEGIES

  • Strict adherence of all healthcare personnel to hand washing guidelines and universal precautions with direct resident contact
  • Pneumococcal vaccination pursuant to current CDC/State Public Health Guidelines for resident and healthcare personnel
  • Oral hygiene assessment and care planning to include daily oral hygiene program that may include intermittent deep oropharyngeal suction (3)
  • Elevate head of bead to 30 degrees with known/suspected/history of aspiration.

(3) Oral Health Affects Pneumonia Risk in the Elderly; Pulmonary Reviews.com, September 2002, Vol. 7, No. 9 (accessed March 2009)

STAFF WORKFLOW PROCESS FOR HIGH PROBABILITY PNEUMONIA RISK

  • Nursing to provide continual general assessment and contact the Physician for recommendations on ABX treatment. Nursing will also monitor the vital signs, cognition level and perform oral hygiene assessment. Will also monitor adherence to daily oral hygiene program.
  • PT/OT to assess patient with attention to mobility concerns and functional abilities.
  • SLP to assess patient with attention to aspiration concerns. (HOB > 30 degrees with known/suspected aspiration history)
  • Dietary to assess patient with attention to nutritional/hydration status.
  • RT will perform RT Screening Assessment with attention to vitals signs including O2 saturation, O2 requirements (if O2 is being utilized), breath sounds, signs of cough, strength and effectiveness of cough effort, sputum production (if applicable). RT will initiate any therapeutic modalities that may be required for the patient. RT will monitor these patients twice/week and record visits per facility documentation protocol.

INTERNATIONAL DISEASE SOCIETY OF AMERICA (IDSA)/CDC GUIDELINES FOR HOSPITAL ADMISSION

(THESE ARE STRICTLY GUIDELINES. FACILITY/PHYSICIAN POLICIES SHOULD BE FOLLOWED)

  • Severely abnormal Vital Signs that may include HR>125, systolic BP<90 or RR>30
  • Alteration in mental status from patient baseline
  • Hypoxemia (pO2<60mmHg on Room Air)
  • Complications such as Emphysema, Septic Arthritis, Endocarditis
  • Severe Hematologic or Chemical abnormalities if different from baseline (Na<130, Hct<30%, ANC<1000, BUN>50, CR>2.5)
  • Co-Morbidity such as COPD, Neoplastic disease, CHF, Cerebrovascular, Renal or Liver disease

QUESTIONS?

BIBLIOGRAPHY

  • Know Pneumonia: The reality versus the Evidence of Diagnosis & Treatment; Levenson S, Crecelius C, Caring for the Ages, August 2003; Vol.4, No. 8, p.14
  • Breathe Easy: Managing Respiratory Infections in LTC Facilities requires well- defined policies, effective surveillance & strong communication; Kaldy J, Caring for the Ages, December 2003
  • Oral Health Affects Pneumonia Risk in the Elderly; Pulmonary Reviews.com, September 2002, Vol. 7, No. 9 (accessed March 2009)
  • Risk Factors for Pneumonia in Nursing Home Patients; Madariaga MG, Thomas A, Cannady PB, NLM Gateway, (a service of the US National Institutes of Health), (accessed March 2009)
  • Modification of the risk of mortality from Pneumonia with oral hygiene care; Bassim CW, Gibson G, Ward T, Paphides BM, Denucci DJ, NLM Gateway, (a service of the US National Institutes of Health), (accessed March 2009)
  • Nursing Home-Acquired Pneumonia: www.Merck.com; Pulmonary Disorders, Pneumonia, review/revision May 2008, Bartlett JG, (accessed March 2009)