Application Of A Community Acquired Pneumonia Guidelines In The Homebased Patient: The AAHCPACCP Pos

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Application 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)
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Elements 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

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Initial 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

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Components 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
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Risk Stratification
Formal e.g., PORT
Versus Informal
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Side 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

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• 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.

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• 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

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Monitoring 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.

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• 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.

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Empiric 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?
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• 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)

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Responsibilities 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.
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• 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.

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• 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.

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Goals 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.
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Patient/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.

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Elements 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

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• 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.

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Closure

• 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.

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• 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.