Pneumonia Core Measure
Community Acquired Pneumonia Core Measure
Core Measure Community Acquired Pneumonia
Today hospitals as businesses, as well as health care institutions, face many obstacles while caring, treating, and rehabilitating patients during their hospital stay. The community as a whole tends to follow a pattern of trends that include specific health conditions including Acute Myocardial Infarction (AMI), Congestive Heart Failure (CHF), and Community Acquired Pneumonia (CAP). These three conditions are part of a collection of diagnoses that have been deemed the title of Core Measures. Core Measures and National Patient Safety Goals were created with the intention of delivering evidence based practice to the bedside to ensure continuity of care. …show more content…
A Core Measure is defined as an evidenced based, scientifically researched standard of care, which has been shown to result in improved clinical outcomes for patients.
The Center for Medicare and Medicaid Services (CMS) established the Core Measures in 2000 and began reporting the data publicly in 2003. The Joint Commission on Accreditation on Healthcare Organizations (JCAHO) created National Patient Safety Goals to promote specific patient safety and to also support the implementation of Core Measures. Other Stakeholders involved with the Core Measure development and implementation include clinicians, hospitals, consumers, and medical societies. (H&HN 2009)
The goal of the core measurements in terms of best practice and standardization of care include a very specific treatment regiment for each established condition. For example, when a patient is admitted to the hospital with Community Acquired Pneumonia (CAP), the standard of care within the CAP core measure includes initiating antibiotic treatment within four hours. This standard of practice has been associated with a 15% lower risk of mortality. As with this example, each core measure has been established as a result of successful and specific evidence based …show more content…
practice.
Compliance with Core Measures is monitored by a purposeful system of checks and balances to ensure proper, efficient implementation as well as financial reimbursement from insurance providers. The checks and balance system begins at the bedside with the nurse/clinician who is accountable to the charge nurse. The Charge Nurse then reports to the Nursing Supervisor, who in turn reports to the individual who is responsible for the Hospital’s Core Measures as a whole. Each hospital fills this specialized position and it can differ from facility to facility, but is typically held by Risk Management. From there, the Hospital reports their compliance and results to JCAHO, who then compares the collective data from all hospitals across the nation
Core measures as established for Community Acquired Pneumonia
These standards of practice have been established in order to create optimal outcomes and improve care for patients admitted with Community Acquired Pneumonia. Those standards of practice are as follows: (a) Obtain Blood Cultures prior to Antibiotic Administration; (b) Antibiotic Administration within 4 hours of arrival; (c) Smoking Cessation Education; (d) Pneumococcal/ Influenza Vaccine Administration. Various scientific and evidenced based researches have identified the rationale for application of these principles outlined below.
A. Blood Cultures Prior to Antibiotics:
For optimal identification, culture and sensitivity of the bacteria causing pneumonia in any given patient, collection of a blood culture prior to antibiotic administration is the preferred practice. Antibiotic administration prior to obtaining blood cultures can impede the growth of the offending bacteria thereby making identification difficult or impossible. Additionally, the bacterial agent may take a longer period to incubate preventing an efficient identification and sensitivity. This could potentially lead to an ineffective or less effective antibiotic being chosen for the patient. This could lead to longer hospital stays, drug resistant bacteria, and increased acuity of the patient. (Weinstein, Reller, & Murphy 1983)
B. Antibiotic Administration within 4 hours of Arrival
Empirical therapy is often recommended in the suspected pneumonia patient. It offers the strongest chance at gaining ground on the offending organisms. It has been shown that empirical therapy demonstrated lower death rates and shorter hospital stays. Though controversy has arisen over the unnecessary exposure of patients to antibiotic therapy, studies have shown that the risk has consistently outweighed the benefits. (Lindsay & DeMarco 2008)
C. Smoking Cessation Education:
Smoking has been identified as the strongest risk factor for pneumococcal pneumonia in healthy non-elderly adults. Studies have demonstrated that smoking cessation dramatically reduces the risk of bacterial pneumonia regardless of age or immune-competency. Structural changes in the respiratory tract due to smoking and subsequent decreased immune response create prime grounds for bacterial pneumonia. Subsequently, providing patients with smoking cessation materials may help to encourage patients to quit smoking upon release from the hospital. Cessation is a health promoting and preventative measure that could reduce the number of people acquiring pneumonia each year. (Gesensway 2008)
D. Pneumococcal/ Influenza vaccination
Vaccination is a major preventative measure against CAP. Streptococcus pneumoniae accounts for 2/3’s of the lethal pneumonia cases annually. Vaccination is a simple preventative measure that can reduce the prevalence and spread of CAP. Providing patients in the hospital with pneumococcal vaccinations, gives the healthcare team the ability to improve compliance with vaccination recommendations. Many have felt that the hospital has been an under-utilized resource for vaccination education and administration.
RN responsibility
The RN’s responsibility to insure that protocols are followed starts before a core measure patient enters a hospital. RNs working in a hospital setting need to be aware that there are certain diagnoses that are core measures and that each core measure has protocols that need to be done while the patient is at the hospital. The nurse admitting the patient can identify early the symptoms that may be a core measure. This can ensure that the patient can get all the essential treatments in a timely matter. A Sierra Vista RN, on any floor, is responsible to make sure the core measure sticker is placed on the chart once the diagnosis of community acquired pneumonia has been made.
The RN needs to see in the chart when the patient was admitted and know that the antibiotic needs to be administered within 4 hours. From there the RN needs to check that the doctor has written an order for a blood culture to be drawn before the first antibiotic administered. After the RN faxes the order to the lab and pharmacy, the RN needs to write in the MAR that the antibiotic ordered is the first one and that the RN needs to check that the lab personnel have gotten the blood culture before the first antibiotic is given. Since the nurse is the one administering the antibiotic, the nurse is the only one to make sure the culture is done before the antibiotic is given. Once the blood culture is drawn and the first antibiotic hung, the RN can initial and date the core measure sticker on the outside of the patient chart.
The smoking cessation education protocol needs to start at admission. The admitting nurse needs to ask the patient if they smoke. If they do, the nurse needs to give them smoking cessation education papers and to make sure the doctor writes an order for nicotine patch. Since Sierra Vista is a non-smoking campus, the patient will need the patch. The RN is responsible for smoking cessation education. Once the RN has given the smoking cessation education information to the patient and has documented the teaching in the chart, the RN can initial and date the core measure sticker on the front of the chart.
The last protocol is the administration of the pneumococcal and/or influenza vaccinations. This is to be done any time before the patient gets discharged from the hospital, if the patient has not already gotten the shot(s). However, at Sierra Vista, every patient over the age 65 gets asked, on admission, if they have had a pneumonia shot and/or a flu shot yet this year. If not, the RN needs to fax the shot form to pharmacy so that the shot(s) get on the daily MAR as a reminder that the shot(s) needs to be done The discharging RN is responsible to look and see if the shot was given during the stay by looking at the daily MARs if the check off sheet was not initialed and dated on the front of the chart. At Sierra Vista, there is another check off sheet inside the beginning of the chart where the RN needs to initial that they have given any of the two shots during the patient’s stay. Before the patient with CAP is discharged, the RN is responsible that all the protocols were done on time and all documentation pertaining to the core measure were complete. In the end, it is not just one RN’s responsibility, but also every RN that comes in contact with the patient from admission to discharge.
Historical and Physical Assessment
Physical History
Patient JH is an 84 year old female who was transported by ambulance to the emergency room (ER) on September 7, 2010 following a fall at home. After breakfast, she had a syncopal episode while on the toilet and fell hitting her head on the left forehead aspect. Her daughter found her on the floor and was unable to move her, so she called emergency medical service (EMS). After the fall, JH was disoriented and continued to be confused on arrival to the ER. Her blood pressure upon arrival was hypotensive at 94/77 mmHg, O2 sat was 98% on a facemask and later she remained at 98% on 4L of oxygen per nasal cannula (NC). She was normothermic with pulse around the 90’s beats per minute (bpm) and respirations were 23 breaths per minute (BPM), which came down to 14 BPM after oxygen treatment. JH has allergies to Neurontin, DNR on file and is attended to by two pulmonologists, the hospitalist in addition to her primeary care physician. A limited activity performance was observed mainly due to severe shortness of breath and hypotension, although she has been getting up with physical therapy for brief periods of ambulation. The patient follows an American Diabetic Association diet due to her diabetic condition and is also on a dysphasia II diet because of her risk for aspiration and her visual loss. Later that day, JH was admitted to the Telemetry unit for exacerbation of COPD and community acquired pneumonia. Among her medical history, the patient was previously diagnosed with severe COPD treated with home oxygen and nebulizer use. She also has asthma, bronchitis, restless leg syndrome, CHF, diabetes, chronic lumbar degenerative disease, rheumatoid arthritis, DVT and CAD. Her past surgical history includes an appendectomy and a thyroid goiter surgery. JH also has a known abdominal aortic aneurysm and has been in and out of the hospital over the last several years for a variety of circulatory and immune conditions including sepsis, cellulitis, rectal bleed and deep tissue abscesses. On top of that, JH is legally blind.
Psychosocial History
JH lives at home with her daughter and up to the point of hospitalization, she had been performing Activities of Daily Living (ADLs) independently. Her daughter expressed concerns and was noticeably upset because of her mothers seemingly rapid decline in health. She stated “I don’t know what happened, she was totally fine a week ago, and even playing cards.”
Laboratory Test and Significance
Blood work was done on JH on arrival to the ER showing a normal white blood count. Troponin was 0.01, Blood Urea Nitrogen (BUN) 19 mg/dL and Creatinine (Cr) 1.0 mg/dL. Her urinalysis was unremarkable except for a 3+ protein count. INR was 1.4 and electrolytes were as follows: Sodium (NA+) 135 mEq/L, Potassium (K+) 4.7 mEq/L, Chloride (CL-) 98 mEq/L, Carbon Dioxide (CO2) 23. Glucose level was 141 mg/dL and Calcium (Ca++) 9.0 mg/dL. Also, an elevated lactic acid level of 3.8 mg/dL was found and some of the liver function tests came back elevated as well. Alkaline phosphatase (ALP) was 151 units/L and Aspartate aminotransferase (AST) was 42 units/L. Moreover, Alanine aminotransferase (ALT) was normal as well as lipase levels and total protein was 6.3
Diagnostic Tests and Pharmacological Interventions
Besides the blood work, an EKG was performed and showed a normal sinus rhythm without any ST-T wave changes.
There was also a chest x-ray done that showed whiteout of the right lung and possible infiltration or tumors in the right lung as well as an enlarged heart. JH had a CT scan done of her brain which came back unremarkable. On September 10th, a chest tube was inserted on JH draining approximately 400ml of serosanguineous fluid. A sample of this was sent to the lab for a gram stain and culture and cytology, it came back negative for bacterial growth and no cancerous cells were seen. A follow-up x-ray on the 12th showed not changes, indicating that she had a mass in her chest and not just fluid. Following the core measures protocol, blood cultures were drawn in the ER and JH was started on Levaquin; the patient was also vaccinated with pneumococcal and tDap. After her blood cultures came back negative, Levaquin was discontinued on September 12th. JH has continued to take her home meds she brought in while hospitalized. Her medication list
includes:
L-thyroxine 125 mcg daily
Furosemide 20 mg daily
Fosinopril 20 mg daily
Methotrexate 2.5 mg 3 x week
Potassium 10 mEq twice daily
Oxygen 2L 24 hours/day
Prednisone 5 mg daily
Omeprazole 20 mg daily
Simvastatin 40 mg daily
Mirapex 0.25 mg at night
Hydroxychloroquine 200 mg daily
Norco 10/325 q 6 hrs
Remicade once q 6 weeks
Advair twice daily
Reclast injection yearly
DuoNeb nebulizer BID
Centrum Silver daily
Vitamin A daily
Vitamin D daily
Folic Acid daily
Calcium Carbonate daily
Warfarin 3 mg daily
Current Assessment
By September 13, JH was alert and oriented x3, cooperative with a flat effect noted. Her physical assessment showed that she moved all extremities well with a steady sitting balance. JH was assisted with ambulation by physical therapist and displayed a rushed unsteady gait. Sensation was intact in all of her extremities. Her pupils were equal at 3mm with a sluggish reaction. On auscultation, a regular pulse with no murmur was noted. Her skin was warm and pink with no edema noted. Her capillary refill was brisk. However, JH had a rash on her back, chest, neck, and upper arms. She had a large bruise on her left temporal region that she states happened from the fall. JH is obese and showed a large, soft abdomen. She has a chest tube on the right thoracic region on low continuous suction that was draining a small amount of serosanguineous fluid. A Foley catheter inserted on September 7 was draining clear, yellow urine to gravity; in addition, active bowel sounds were observed and patient manifested having her last bowel movement (BM) 4 days ago. JH had diminished lung sounds in the bases with slight crackles in her upper right lobe and expiratory wheezing on the right side was noted. Her O2 saturation was 96% on 2L per NC. Respirations were 20 BPM and labored. JH also had a saline lock in her right antecubital. On September 13th, her pulmonologist ordered a fine needle biopsy of her right lung mass to determine the pathology. This procedure was to be done at interventional radiology and her chest tube was ordered to be removed at the same time. JH was receiving respiratory treatments every 4 hours and PRN. On the same day, her white blood cells (WBC) came back at 8.5 mg/dL, which supports the MD’s speculation that she did not have pneumonia and perhaps never did. Without a definitive diagnosis, the physicians could only discuss possible diagnosis and optional treatments. JH was aware of her general condition, but had a limited understanding of what her physicians discussed with her. Upon hearing that there was a possibility that her lung mass was cancerous, she immediately focused on the potential diagnosis.
Teaching Interventions
Patient teaching for JH included reinforcing that she was not actually diagnosed with lung cancer and that there were still tests that needed to be done to make a definitive diagnosis. Including the immediate family in this teaching was important as they were very anxious and upset to hear that the physician had discussed a possibility of cancer.
JH was encouraged to use her incentive spirometer every hour while awake and she demonstrated proper use of the device. Deep breathing and coughing was also discussed with JH as an effort to increase her lungs oxygenation capacity. Prior to the lung biopsy, the nurse explained to JH that she might experience minor discomfort during the procedure and that multiple biopsies may be necessary. Smoking cessation education was not discussed with JH because even though she was a smoker for years, she had quit 20 years prior. (i.e. Sierra Vista Hospital chart of JH)
Implications for not following core measures
Core measures are nurse driven; the nurse is in charge to make sure all of the interventions are carried out in a timely fashion. When those standards are not met, not only are the patients affected, but the RNs and facility that cared for those patients are affected too.
When a patient is admitted with community acquired pneumonia (CAP) a list of core measures are implemented for that patient, which are: blood cultures, antibiotics (Initial antibiotic selection consistent with current recommendations) within 4 hours of arriving at the hospital, smoking cessation education, and pneumococcal and influenza screening/vaccinations.
Throughout the course of the patient’s hospital stay, all of the core measures should be implemented and documented by the RNs taking care of the patient; it is after all the nurses’ responsibility. When an RN is employed at a hospital, they are educated on the core measures and the importance to implement that knowledge while caring for these patients. If the RN(s) fail to complete all the core measures before a patient is discharged, the director will check through the medical records of the patient and see which RNs have been involved and which could have completed the core measures of that patient, and they talk with them about why they didn’t complete a particular measure. The director will then educate the RN(s) appropriately, whether it was the RN did complete the measure, but forgot to document it, or they forgot to implement the measure or didn’t know; re-educating them on the importance and protocol of core measures is essential.
Disciplinary action will be taken if an RN is habitually neglecting core measures; they are after all caring for a patient’s life (N. Edwards, RN, personal communication, October 6, 2010). When an RN doesn’t follow through on a core measure it is recorded, along with all the other core measure patients (whether the core measures are completed or not) and these are made into reports. Hospital regulatory agencies such as JCAHO monitor hospitals and receive reports on all core measure patients. The data is then rated and becomes public knowledge, essentially giving the hospital a grade for all to see. If a hospital is performing poorly with their core measure protocol they will not have a very high rating, and therefore less patient’s will want to come to that hospital, less staff will want employment there, and less physicians will want to practice there. As if that isn’t bad enough, insurance agencies reimburse hospitals less based on their ratings (N. Edwards, RN, personal communication, October 6, 2010).
Although most hospitals are for profit, they are firstly for the patient. If a patient is not receiving appropriate care for their CAP, by following the core measures, research has shown that there are health implications. If, for example, the patient does not receive the recommended antibiotic within the allotted time, their hospital stay may be extended; they will be suffering with this infection longer than they should be, and the likelihood of them returning to the hospital with a CAP in the near future is that much greater. Medicare patients returning to the hospital within 30 days of discharge with a core measure will be cared for on the hospitals dollar. One can surmise that this alone will encourage completion of core measures every time (N. Edwards, RN, personal communication, October 6, 2010).
References
Deborah Gesensway (March 2008). New thinking on antibiotic timing in CAP patients.
Today 's Hospitalist http://www.todayshospitalist.com/index.php?b=articles_read&cnt=526 H&HN: Hospitals & Health Networks (2009). CMS compliance: tracking performance with core measures. Health Services Administration; USA, Vol. 83, Issue 11. Retrieved October 20, 2010 from EBSCOhost
Lindsay M; DeMarco F; Academic Journal Measures. Critical Care Nurse, 2008 Apr; 28 (2): e18-9 ISSN: 0279-5442 Retrieved October 22, 2010 from CINAHL AN: 2010251977
New England Journal of Medicine (March 2000: 342 (10); 681-689
Weinstein MP, Reller LP, Murphy JR, et al. The clinical significance of positive blood cultures:
A comprehensive analysis of 500 episodes of bacteremia and fungemia in adults. I. Laboratory and epidemiologic observations. Reviews of Infectious Diseases. 1983;5:35–53.
Core Measure Community Acquired Pneumonia
Today hospitals as businesses, as well as health care institutions, face many obstacles while caring, treating, and rehabilitating patients during their hospital stay. The community as a whole tends to follow a pattern of trends that include specific health conditions including Acute Myocardial Infarction (AMI), Congestive Heart Failure (CHF), and Community Acquired Pneumonia (CAP). These three conditions are part of a collection of diagnoses that have been deemed the title of Core Measures. Core Measures and National Patient Safety Goals were created with the intention of delivering evidence based practice to the bedside to ensure continuity of care. …show more content…
A Core Measure is defined as an evidenced based, scientifically researched standard of care, which has been shown to result in improved clinical outcomes for patients.
The Center for Medicare and Medicaid Services (CMS) established the Core Measures in 2000 and began reporting the data publicly in 2003. The Joint Commission on Accreditation on Healthcare Organizations (JCAHO) created National Patient Safety Goals to promote specific patient safety and to also support the implementation of Core Measures. Other Stakeholders involved with the Core Measure development and implementation include clinicians, hospitals, consumers, and medical societies. (H&HN 2009)
The goal of the core measurements in terms of best practice and standardization of care include a very specific treatment regiment for each established condition. For example, when a patient is admitted to the hospital with Community Acquired Pneumonia (CAP), the standard of care within the CAP core measure includes initiating antibiotic treatment within four hours. This standard of practice has been associated with a 15% lower risk of mortality. As with this example, each core measure has been established as a result of successful and specific evidence based …show more content…
practice.
Compliance with Core Measures is monitored by a purposeful system of checks and balances to ensure proper, efficient implementation as well as financial reimbursement from insurance providers. The checks and balance system begins at the bedside with the nurse/clinician who is accountable to the charge nurse. The Charge Nurse then reports to the Nursing Supervisor, who in turn reports to the individual who is responsible for the Hospital’s Core Measures as a whole. Each hospital fills this specialized position and it can differ from facility to facility, but is typically held by Risk Management. From there, the Hospital reports their compliance and results to JCAHO, who then compares the collective data from all hospitals across the nation
Core measures as established for Community Acquired Pneumonia
These standards of practice have been established in order to create optimal outcomes and improve care for patients admitted with Community Acquired Pneumonia. Those standards of practice are as follows: (a) Obtain Blood Cultures prior to Antibiotic Administration; (b) Antibiotic Administration within 4 hours of arrival; (c) Smoking Cessation Education; (d) Pneumococcal/ Influenza Vaccine Administration. Various scientific and evidenced based researches have identified the rationale for application of these principles outlined below.
A. Blood Cultures Prior to Antibiotics:
For optimal identification, culture and sensitivity of the bacteria causing pneumonia in any given patient, collection of a blood culture prior to antibiotic administration is the preferred practice. Antibiotic administration prior to obtaining blood cultures can impede the growth of the offending bacteria thereby making identification difficult or impossible. Additionally, the bacterial agent may take a longer period to incubate preventing an efficient identification and sensitivity. This could potentially lead to an ineffective or less effective antibiotic being chosen for the patient. This could lead to longer hospital stays, drug resistant bacteria, and increased acuity of the patient. (Weinstein, Reller, & Murphy 1983)
B. Antibiotic Administration within 4 hours of Arrival
Empirical therapy is often recommended in the suspected pneumonia patient. It offers the strongest chance at gaining ground on the offending organisms. It has been shown that empirical therapy demonstrated lower death rates and shorter hospital stays. Though controversy has arisen over the unnecessary exposure of patients to antibiotic therapy, studies have shown that the risk has consistently outweighed the benefits. (Lindsay & DeMarco 2008)
C. Smoking Cessation Education:
Smoking has been identified as the strongest risk factor for pneumococcal pneumonia in healthy non-elderly adults. Studies have demonstrated that smoking cessation dramatically reduces the risk of bacterial pneumonia regardless of age or immune-competency. Structural changes in the respiratory tract due to smoking and subsequent decreased immune response create prime grounds for bacterial pneumonia. Subsequently, providing patients with smoking cessation materials may help to encourage patients to quit smoking upon release from the hospital. Cessation is a health promoting and preventative measure that could reduce the number of people acquiring pneumonia each year. (Gesensway 2008)
D. Pneumococcal/ Influenza vaccination
Vaccination is a major preventative measure against CAP. Streptococcus pneumoniae accounts for 2/3’s of the lethal pneumonia cases annually. Vaccination is a simple preventative measure that can reduce the prevalence and spread of CAP. Providing patients in the hospital with pneumococcal vaccinations, gives the healthcare team the ability to improve compliance with vaccination recommendations. Many have felt that the hospital has been an under-utilized resource for vaccination education and administration.
RN responsibility
The RN’s responsibility to insure that protocols are followed starts before a core measure patient enters a hospital. RNs working in a hospital setting need to be aware that there are certain diagnoses that are core measures and that each core measure has protocols that need to be done while the patient is at the hospital. The nurse admitting the patient can identify early the symptoms that may be a core measure. This can ensure that the patient can get all the essential treatments in a timely matter. A Sierra Vista RN, on any floor, is responsible to make sure the core measure sticker is placed on the chart once the diagnosis of community acquired pneumonia has been made.
The RN needs to see in the chart when the patient was admitted and know that the antibiotic needs to be administered within 4 hours. From there the RN needs to check that the doctor has written an order for a blood culture to be drawn before the first antibiotic administered. After the RN faxes the order to the lab and pharmacy, the RN needs to write in the MAR that the antibiotic ordered is the first one and that the RN needs to check that the lab personnel have gotten the blood culture before the first antibiotic is given. Since the nurse is the one administering the antibiotic, the nurse is the only one to make sure the culture is done before the antibiotic is given. Once the blood culture is drawn and the first antibiotic hung, the RN can initial and date the core measure sticker on the outside of the patient chart.
The smoking cessation education protocol needs to start at admission. The admitting nurse needs to ask the patient if they smoke. If they do, the nurse needs to give them smoking cessation education papers and to make sure the doctor writes an order for nicotine patch. Since Sierra Vista is a non-smoking campus, the patient will need the patch. The RN is responsible for smoking cessation education. Once the RN has given the smoking cessation education information to the patient and has documented the teaching in the chart, the RN can initial and date the core measure sticker on the front of the chart.
The last protocol is the administration of the pneumococcal and/or influenza vaccinations. This is to be done any time before the patient gets discharged from the hospital, if the patient has not already gotten the shot(s). However, at Sierra Vista, every patient over the age 65 gets asked, on admission, if they have had a pneumonia shot and/or a flu shot yet this year. If not, the RN needs to fax the shot form to pharmacy so that the shot(s) get on the daily MAR as a reminder that the shot(s) needs to be done The discharging RN is responsible to look and see if the shot was given during the stay by looking at the daily MARs if the check off sheet was not initialed and dated on the front of the chart. At Sierra Vista, there is another check off sheet inside the beginning of the chart where the RN needs to initial that they have given any of the two shots during the patient’s stay. Before the patient with CAP is discharged, the RN is responsible that all the protocols were done on time and all documentation pertaining to the core measure were complete. In the end, it is not just one RN’s responsibility, but also every RN that comes in contact with the patient from admission to discharge.
Historical and Physical Assessment
Physical History
Patient JH is an 84 year old female who was transported by ambulance to the emergency room (ER) on September 7, 2010 following a fall at home. After breakfast, she had a syncopal episode while on the toilet and fell hitting her head on the left forehead aspect. Her daughter found her on the floor and was unable to move her, so she called emergency medical service (EMS). After the fall, JH was disoriented and continued to be confused on arrival to the ER. Her blood pressure upon arrival was hypotensive at 94/77 mmHg, O2 sat was 98% on a facemask and later she remained at 98% on 4L of oxygen per nasal cannula (NC). She was normothermic with pulse around the 90’s beats per minute (bpm) and respirations were 23 breaths per minute (BPM), which came down to 14 BPM after oxygen treatment. JH has allergies to Neurontin, DNR on file and is attended to by two pulmonologists, the hospitalist in addition to her primeary care physician. A limited activity performance was observed mainly due to severe shortness of breath and hypotension, although she has been getting up with physical therapy for brief periods of ambulation. The patient follows an American Diabetic Association diet due to her diabetic condition and is also on a dysphasia II diet because of her risk for aspiration and her visual loss. Later that day, JH was admitted to the Telemetry unit for exacerbation of COPD and community acquired pneumonia. Among her medical history, the patient was previously diagnosed with severe COPD treated with home oxygen and nebulizer use. She also has asthma, bronchitis, restless leg syndrome, CHF, diabetes, chronic lumbar degenerative disease, rheumatoid arthritis, DVT and CAD. Her past surgical history includes an appendectomy and a thyroid goiter surgery. JH also has a known abdominal aortic aneurysm and has been in and out of the hospital over the last several years for a variety of circulatory and immune conditions including sepsis, cellulitis, rectal bleed and deep tissue abscesses. On top of that, JH is legally blind.
Psychosocial History
JH lives at home with her daughter and up to the point of hospitalization, she had been performing Activities of Daily Living (ADLs) independently. Her daughter expressed concerns and was noticeably upset because of her mothers seemingly rapid decline in health. She stated “I don’t know what happened, she was totally fine a week ago, and even playing cards.”
Laboratory Test and Significance
Blood work was done on JH on arrival to the ER showing a normal white blood count. Troponin was 0.01, Blood Urea Nitrogen (BUN) 19 mg/dL and Creatinine (Cr) 1.0 mg/dL. Her urinalysis was unremarkable except for a 3+ protein count. INR was 1.4 and electrolytes were as follows: Sodium (NA+) 135 mEq/L, Potassium (K+) 4.7 mEq/L, Chloride (CL-) 98 mEq/L, Carbon Dioxide (CO2) 23. Glucose level was 141 mg/dL and Calcium (Ca++) 9.0 mg/dL. Also, an elevated lactic acid level of 3.8 mg/dL was found and some of the liver function tests came back elevated as well. Alkaline phosphatase (ALP) was 151 units/L and Aspartate aminotransferase (AST) was 42 units/L. Moreover, Alanine aminotransferase (ALT) was normal as well as lipase levels and total protein was 6.3
Diagnostic Tests and Pharmacological Interventions
Besides the blood work, an EKG was performed and showed a normal sinus rhythm without any ST-T wave changes.
There was also a chest x-ray done that showed whiteout of the right lung and possible infiltration or tumors in the right lung as well as an enlarged heart. JH had a CT scan done of her brain which came back unremarkable. On September 10th, a chest tube was inserted on JH draining approximately 400ml of serosanguineous fluid. A sample of this was sent to the lab for a gram stain and culture and cytology, it came back negative for bacterial growth and no cancerous cells were seen. A follow-up x-ray on the 12th showed not changes, indicating that she had a mass in her chest and not just fluid. Following the core measures protocol, blood cultures were drawn in the ER and JH was started on Levaquin; the patient was also vaccinated with pneumococcal and tDap. After her blood cultures came back negative, Levaquin was discontinued on September 12th. JH has continued to take her home meds she brought in while hospitalized. Her medication list
includes:
L-thyroxine 125 mcg daily
Furosemide 20 mg daily
Fosinopril 20 mg daily
Methotrexate 2.5 mg 3 x week
Potassium 10 mEq twice daily
Oxygen 2L 24 hours/day
Prednisone 5 mg daily
Omeprazole 20 mg daily
Simvastatin 40 mg daily
Mirapex 0.25 mg at night
Hydroxychloroquine 200 mg daily
Norco 10/325 q 6 hrs
Remicade once q 6 weeks
Advair twice daily
Reclast injection yearly
DuoNeb nebulizer BID
Centrum Silver daily
Vitamin A daily
Vitamin D daily
Folic Acid daily
Calcium Carbonate daily
Warfarin 3 mg daily
Current Assessment
By September 13, JH was alert and oriented x3, cooperative with a flat effect noted. Her physical assessment showed that she moved all extremities well with a steady sitting balance. JH was assisted with ambulation by physical therapist and displayed a rushed unsteady gait. Sensation was intact in all of her extremities. Her pupils were equal at 3mm with a sluggish reaction. On auscultation, a regular pulse with no murmur was noted. Her skin was warm and pink with no edema noted. Her capillary refill was brisk. However, JH had a rash on her back, chest, neck, and upper arms. She had a large bruise on her left temporal region that she states happened from the fall. JH is obese and showed a large, soft abdomen. She has a chest tube on the right thoracic region on low continuous suction that was draining a small amount of serosanguineous fluid. A Foley catheter inserted on September 7 was draining clear, yellow urine to gravity; in addition, active bowel sounds were observed and patient manifested having her last bowel movement (BM) 4 days ago. JH had diminished lung sounds in the bases with slight crackles in her upper right lobe and expiratory wheezing on the right side was noted. Her O2 saturation was 96% on 2L per NC. Respirations were 20 BPM and labored. JH also had a saline lock in her right antecubital. On September 13th, her pulmonologist ordered a fine needle biopsy of her right lung mass to determine the pathology. This procedure was to be done at interventional radiology and her chest tube was ordered to be removed at the same time. JH was receiving respiratory treatments every 4 hours and PRN. On the same day, her white blood cells (WBC) came back at 8.5 mg/dL, which supports the MD’s speculation that she did not have pneumonia and perhaps never did. Without a definitive diagnosis, the physicians could only discuss possible diagnosis and optional treatments. JH was aware of her general condition, but had a limited understanding of what her physicians discussed with her. Upon hearing that there was a possibility that her lung mass was cancerous, she immediately focused on the potential diagnosis.
Teaching Interventions
Patient teaching for JH included reinforcing that she was not actually diagnosed with lung cancer and that there were still tests that needed to be done to make a definitive diagnosis. Including the immediate family in this teaching was important as they were very anxious and upset to hear that the physician had discussed a possibility of cancer.
JH was encouraged to use her incentive spirometer every hour while awake and she demonstrated proper use of the device. Deep breathing and coughing was also discussed with JH as an effort to increase her lungs oxygenation capacity. Prior to the lung biopsy, the nurse explained to JH that she might experience minor discomfort during the procedure and that multiple biopsies may be necessary. Smoking cessation education was not discussed with JH because even though she was a smoker for years, she had quit 20 years prior. (i.e. Sierra Vista Hospital chart of JH)
Implications for not following core measures
Core measures are nurse driven; the nurse is in charge to make sure all of the interventions are carried out in a timely fashion. When those standards are not met, not only are the patients affected, but the RNs and facility that cared for those patients are affected too.
When a patient is admitted with community acquired pneumonia (CAP) a list of core measures are implemented for that patient, which are: blood cultures, antibiotics (Initial antibiotic selection consistent with current recommendations) within 4 hours of arriving at the hospital, smoking cessation education, and pneumococcal and influenza screening/vaccinations.
Throughout the course of the patient’s hospital stay, all of the core measures should be implemented and documented by the RNs taking care of the patient; it is after all the nurses’ responsibility. When an RN is employed at a hospital, they are educated on the core measures and the importance to implement that knowledge while caring for these patients. If the RN(s) fail to complete all the core measures before a patient is discharged, the director will check through the medical records of the patient and see which RNs have been involved and which could have completed the core measures of that patient, and they talk with them about why they didn’t complete a particular measure. The director will then educate the RN(s) appropriately, whether it was the RN did complete the measure, but forgot to document it, or they forgot to implement the measure or didn’t know; re-educating them on the importance and protocol of core measures is essential.
Disciplinary action will be taken if an RN is habitually neglecting core measures; they are after all caring for a patient’s life (N. Edwards, RN, personal communication, October 6, 2010). When an RN doesn’t follow through on a core measure it is recorded, along with all the other core measure patients (whether the core measures are completed or not) and these are made into reports. Hospital regulatory agencies such as JCAHO monitor hospitals and receive reports on all core measure patients. The data is then rated and becomes public knowledge, essentially giving the hospital a grade for all to see. If a hospital is performing poorly with their core measure protocol they will not have a very high rating, and therefore less patient’s will want to come to that hospital, less staff will want employment there, and less physicians will want to practice there. As if that isn’t bad enough, insurance agencies reimburse hospitals less based on their ratings (N. Edwards, RN, personal communication, October 6, 2010).
Although most hospitals are for profit, they are firstly for the patient. If a patient is not receiving appropriate care for their CAP, by following the core measures, research has shown that there are health implications. If, for example, the patient does not receive the recommended antibiotic within the allotted time, their hospital stay may be extended; they will be suffering with this infection longer than they should be, and the likelihood of them returning to the hospital with a CAP in the near future is that much greater. Medicare patients returning to the hospital within 30 days of discharge with a core measure will be cared for on the hospitals dollar. One can surmise that this alone will encourage completion of core measures every time (N. Edwards, RN, personal communication, October 6, 2010).
References
Deborah Gesensway (March 2008). New thinking on antibiotic timing in CAP patients.
Today 's Hospitalist http://www.todayshospitalist.com/index.php?b=articles_read&cnt=526 H&HN: Hospitals & Health Networks (2009). CMS compliance: tracking performance with core measures. Health Services Administration; USA, Vol. 83, Issue 11. Retrieved October 20, 2010 from EBSCOhost
Lindsay M; DeMarco F; Academic Journal Measures. Critical Care Nurse, 2008 Apr; 28 (2): e18-9 ISSN: 0279-5442 Retrieved October 22, 2010 from CINAHL AN: 2010251977
New England Journal of Medicine (March 2000: 342 (10); 681-689
Weinstein MP, Reller LP, Murphy JR, et al. The clinical significance of positive blood cultures:
A comprehensive analysis of 500 episodes of bacteremia and fungemia in adults. I. Laboratory and epidemiologic observations. Reviews of Infectious Diseases. 1983;5:35–53.