Title: Application Of A Community Acquired Pneumonia Guidelines In The Homebased Patient: The AAHCPACCP Pos
1Application Of A Community Acquired Pneumonia
Guidelines In The Home-based Patient The
AAHCP/ACCP Position Statement
- Joe Ramsdell M.D.
- AAHCP May 4, 2006
Ramsdell JW, et. al., Management of Community
Acquired Pneumonia in the Home ACCP Clinical
Position Statement. Chest 2005,127(5)1752-63
(endorsed by the ATS, AARC AGS)
2Elements Of In-home Treatment Of CAP
- Initial patient evaluation and diagnosis in the
home environment - Determination of site of care
- Elements of an in-home management plan
- Patient and caregiver commitment to the care plan
- Goals for nurses providing interim home care
- Monitoring assessment of risk of recurrence
preventive measures and closure
3Initial Patient Evaluation and Diagnosis in the
Home Environment
- The initial evaluation should be performed in
person by a qualified provider (i.e., a
physician, nurse practitioner, or physician
assistant) or by a visiting home nurse in contact
with a qualified provider at the time of the
evaluation. In this case, the qualified provider
must evaluate the patient within 24 hours of the
initial diagnosis. Telephone triage alone is not
acceptable. - If a qualified provider does not meet with the
patient at the time of the initial evaluation,
the provider must see the patient sometime
between presentation and closure. - Repeat assessment should be performed within 24
hours for the high-risk patient
4Components Of The Initial Evaluation In Patients
With Suspected CAP
- History and physical examination
- Chest radiograph
- Oxygen saturation or arterial blood gas
- CBC
- Chemistry panel
- Blood cultures
- Risk stratification
Consider in selected patients
5Risk Stratification
Formal e.g., PORT
Versus Informal
6Side Of Care Issues
- Appropriate risk factors on initial evaluation
- Consistent with patients informed wishes
(written advanced directives should be confirmed
at the time of diagnosis of CAP with the patient
or surrogate) - Care contract, preferably formal, in place
7- Determinants Of Site Of Care
- The patient is not clinically unstable and/or
- The patients or the familys goals indicate that
aggressive medical or surgical interventions
should be urgently initiated. - Critical diagnostic tests are available in the
home. - All necessary therapy is available in the home,
and the frequency of dosing and the intensity of
monitoring the therapy are not beyond the
capacity of the caregiver(s). - Comfort measures can be assured in the home.
- Specific infection control measures are available
in the home.
8- ELEMENTS OF THE IN-HOME TREATMENT PLAN
- A safe and secure home environment
- Caregiver education (i.e., monitoring and
treatment responsibilities) - In-home capability to carry out treatment plan
- Antibiotics choice
- Oxygenation
- Smoking cessation
- Hydration
- Nutrition
- Maintenance of functional capacity
(ADL?/Instrumental ADL) - Energy conservation
- Treatment of ancillary symptoms (e.g., cough,
pain, etc.) - Treatment of coexisting illnesses (e.g.,
diabetes, chronic ventilatory insufficiency,
etc.) - Professional follow up
- Support services
9Monitoring and Closure
- The frequency of follow up visits to the home or
patient visits to the clinic/office should be a
written component of the initial plan and should
be revised as needed. - End of episode assessment includes consideration
of progress in return to baseline functional
state. - A house call practice should establish a process
for ongoing review and analysis of cases in which
patients are transferred to an acute care
facility or to an emergency department, even when
the patient returns home without admission.
10- Initial Empirical Treatment Of CAP In Low Risk
Patients - Macrolide (erythromycin, clarithromycin, or
azithromycin). Clarithromycin and azithromycin
are recommended if Hemophilus influenzae is
suspected. - Doxycycline.
- Fluoroquinolone (levofloxacin, moxifloxacin,
gatifloxacin, or other agent with enhanced
activity against S. pneumoniae).
- based on the empiric therapy guidelines of the
IDSA and ATS.
11Empiric Treatment Of High Risk Patients With CAP
- A patient of high risk either because of
complicated co-morbidities or extensive prior
antibiotic use maybe a candidate for treatment
with either a ß-lactum/macrolide combination or
an anti-pneumococcal fluoroquinolone. - Double therapy with either a ß-lactum/macrolide
combination or a ß-lactam/antipneumococcal
fluoroquinolone should be considered in patients
that would normally be considered for ICU
admission but chose to remain in the home.
Whats A High Risk Patient?
12- Modifying Factors That Increase The Risk Of
Infection With Specific Pathogens - Penicillin-resistant And Drug-resistant
Pneumococci - Age gt 65 yr
- ?-Lactam therapy within the past 3 months
- Alcoholism
- Immune-suppressive illness (including therapy
with corticosteroids) - Multiple medical co-morbidities
- Exposure to a child in a day care center
- Enteric Gram-negatives
- Residence in a nursing home
- Underlying cardiopulmonary disease
- Multiple medical co-morbidities
- Recent antibiotic therapy
- Pseudomonas aeruginosa
- Structural lung disease (bronchiectasis)
- Corticosteroid therapy (10 mg of prednisone per
day)
13Responsibilities for Home Medical Equipment (HME)
If HME is required (e.g., home O2) it is the
responsibility of the qualified provider making
the diagnosis or his/her designee to assure that
the equipment is delivered within the timelines
of these requirements, that it is in good
operating order and that the patient and/or
caregiver are educated in its proper use and
maintenance.
14- Appropriate Time Lines For The Principal Elements
Of In-home Management Of CAP - The first dose of antibiotic should be
administered within 4-8 hours of presentation. - Oxygenation should be optimized within 4-8 hours
of presentation. - If hydration is necessary, it should be initiated
within 4-8 hours of presentation.
15- Elements of a Contract for Participation in
Home Care - The purpose of this contract is to promote
understanding of the care the patient (specify
name) is to receive at home and to identify the
responsibilities of both the patient/caregiver
and the provider in ensuring that the patients
needs are met. - The patient/caregiver agrees to
- Learn to provide the care required including use
of medications, ensuring adequate fluids,
appropriate diet and nutrition, and recommended
pulmonary therapy. - Take medications and other treatments (e.g.,
oxygen or nebulization) as indicated by the
provider. - Follow recommendations to improve gas exchange
including coughing, deep breathing, and proper
positioning. - Minimize energy expenditures and ensure adequate
rest. - Notify the provider of fever above (of),
increased difficulty breathing, worsening of
cough or sputum, or other symptoms as indicated
by the provider. - Participate with the patient/caregiver in the
planning and provision of care. - Make and keep appointments as recommended by the
provider. - The provider agrees to
- Provide appropriate treatments, instruction,
assessment, and evaluation to the
patient/caregiver. - the
- Agree to transfer to an acute care facility if
recommended by the provider.
16Goals for Nurses Providing Interim Home Care in
CAP
- Patient/caregiver education
- Monitoring
if a provider chooses not to refer a patient to
a home care agency, the standards for interim
care must still be met.
17Patient/Caregiver Education Goals For Nurses
Providing Interim Home Care In CAP
- Understand pneumonia (e.g., causes, preventive
measures, and clinical implications) - Recognize worsening signs and symptoms and
occurrence of complications and know what to do - Make and keep medical appointments
- Adapt lifestyle to maintain adequate hydration,
decrease aggravating behaviors, comply with
coughing and deep breathing exercises - Monitor temperature and sputum production
- Understand and comply with medication regimen and
diet - Understand use and cleaning of respiratory
equipment (e.g., mini-nebulizer) - Follow the care plan to maintain vital signs,
respiratory status, oximetry measurements within
provider established parameters - Activity prescription, including physical therapy
evaluation if needed, to avoid deconditioning,
skin breakdown, etc.
18Elements Of The Visiting Nurses Home Monitoring
Of Patients With CAP
- Vital signs temperature, pulse, respiratory
rate, and blood pressure - Cardiopulmonary signs and symptoms chest pain,
shortness of breath, cough, heart and breath
sounds, edema, oxygen use, oximetry, weight - Mental status
- Nutrition and hydration status and compliance
with diet appetite nausea/vomiting, constipation - Urinary frequency and output
- Skin integrity, turgor
- Lower extremity pain, pulses, color, swelling
- Mobility and use of assistive devices
- Psychosocial status and coping ability
- Medication compliance
- Status of problem list indicating the problem and
the date and time the problem was both identified
and resolved
19- Transfer From In-Home Care
- If the management goals cannot be achieved in the
home care setting or the treatment plan is
failing then transfer to an acute care facility
should be considered. - When a transfer decision is made, the rationale
for referral to the emergency department, or
hospitalization, should be documented in a
progress note in the patients medical record.
20Closure
- There should be a closure visit for each patient
during which risk of recurrence is evaluated,
preventive measures are discussed and functional
status is assessed. - A chest radiograph should be obtained to confirm
resolution of the illness a minimum of 8 weeks
following diagnosis.
21- Initial Patient Evaluation and Diagnosis in the
Home Environment - A qualified provider includes a physician, nurse
practitioner, or physician assistant. - 2. The initial evaluation should be performed in
person by a qualified provider or by a visiting
home nurse in contact with a qualified provider
at the time of the evaluation. In this case, the
qualified provider must evaluate the patient
within 24 hours of the initial diagnosis.
Telephone triage alone is not acceptable. - If a qualified provider does not meet with the
patient at the time of the initial evaluation,
the provider must see the patient sometime
between presentation and closure. - Determination of Site of Care
- 4. Home care should be an option if it can
provide the same level of quality and achieve the
same level of recovery and functional status,
consistent with the patients wishes and overall
treatment goals, as would be possible at any
other site of care. - 5. Care should be provided in a timely fashion.
If these goals cannot be achieved in the home
care setting, transfer to an acute care facility
should be considered. - The first dose of antibiotic should be
administered within 8 hours of presentation. - Oxygenation should be optimized within 8 hours of
presentation. - Hydration should be initiated within 8 hours of
presentation. - If a Patient Care Contract cannot be agreed to or
is violated, transfer to an acute care facility
should occur. - Management of CAP at Home
- The patient should be treated with antibiotics
based on the empiric therapy guidelines of the
ATS and IDSA. - Monitoring and Goals for Nurses Providing Interim
Home Care - 8. Repeat assessment should be performed within
24 hours for the high-risk patient. - 9. If a provider chooses not to refer a patient
to a home care agency, the standards for interim
care must still be met.