Pneumonia (PN) Frequently Asked Questions (FAQs) 2Q09 and 3Q09. Adult Smoking History. Another Suspected Source of Infection

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1 Pneumonia (PN) Frequently Asked Questions (FAQs) Adult Smoking History The nurse wrote patient smoker for 15 years but does not indicate when or if he quit. The physician in the H&P wrote "The patient is not a smoker". The patient has severe brain injury and lives in a nursing home and is paralyzed on the right side. Family is considering withdrawing treatment if there is no cognitive improvement in a month. Would this be yes or no for smoker?" This will be a No, since there is nothing to indicate the patient currently smokes or has within the last 12 months. Another Suspected Source of Infection Would TB be considered another suspected source of infection on arrival. For the data element Another Suspected Source of Infection this will abstract as a No because infections of the respiratory tract are excluded. Was there another suspected source of infection in addition to PN? In the MD's discharge summary he writes "pericarditis and colitis". Is this considered another source of infection? For PN data element Another Suspected Source of Infection, this will abstract as No. If there had been documentation that the colitis was due to a bacterial infection like C diff, this would abstract as Yes. Antibiotic Administered A patient was admitted from the ED. There is no documentation of one of the ordered antibiotics being administered. We utilize an electronic MAR. The following documentation appears by the inpatient nurse: Zithromax 500 mg IV (inpatient nurse's mnemonic) at 1520 Given in ED Gave:250mls. Although I know this indicates the medication was not given on the inpatient unit, because of the wording Gave 250 mls., must I still abstract this as being given at 1520? PN FAQs Page 1 of 11

2 You can't use documentation on an inpatient MAR 'given in ER" since this does not demonstrate antibiotic administration. GIVEN IN THE ER ON MAR - is not sufficient to say that dose was given. You should abstract the earliest dose documented as administered. In this scenario, since the nurse documented with her mnemonic at 1316 and this is the earliest time, 1316 should be entered. Noted per ER record, Levaquin IV with a 1240 time however, it is then crossed out with "error" written on top, "infiltrated" written to side, and initialed. Do I use the 1240 since it appears the med was started and then infiltrated? Yes, you would take this per the Note for Abstraction: If an antibiotic is started and the infusion is interrupted by an event such as the IV being dislodged...abstract the time the infusion was started Can we use nursing documentation in the ED nursing notes? Abstract antibiotics from narrative charting ONLY if there is no other documentation that reflects that antibiotic was given. Antibiotic Allergy Pt states allergic to Avelox. Would this be a yes to allergy to antibiotics? Avelox is not listed in the side bar. For the data element, Antibiotic Allergy, we are only interested in allergies for beta-lactams and cephalosporins, so that is all that is on the table. If a patient has a documented beta-lactam allergy, this opens up more antimicrobial regimens. Avelox (Moxifloxacin) is a Quinolone so this will abstract as No. Antibiotic Received Levaquin is not listed on the patient Med Recon, and there is no documentation that the medication was given within 24 hours of arrival. However, the DC Summary states:"...was being treated with Levaquin as an outpatient for Pneumonia when family noted twitching and she was brought to the ED...". Is this sufficient documentation to answer "yes" to 'antibiotic received within 24 hours of arrival? PN FAQs Page 2 of 11

3 For the data Antibiotic Received there is not enough documentation to support antibiotic received within 24 hours of hospital arrival or the day prior to arrival. If the antibiotic is listed as a current home med or on the medication reconciliation form, you can assume this was taken prior to arrival. However, do not make assumptions with other documentation. You can t tell from the documentation on the discharge summary when the patient last took the Levaquin. How do I answer antibiotic received if in H&P under current meds, ED and Medication Reconciliation form it states patient was on an unknown antibiotic? For the data element Antibiotic Received this would abstract as antibiotic received prior to arrival. Antibiotic Selection Pt admitted from the nursing home. Was on po Levaquin outpt. MD started Rocehin and nothing else in the ER. Will this pass the measure? Rocephin (B Lactam) alone will not pass the antibiotic selection measure PN 6. For patients not admitted to the ICU, the guideline clearly recommends B Lactam (IV or IM) Table Macrolide (IV or oral) Table 2.5 OR Antipneumococcal Quinolone monotherapy (IV or oral) Table 2.9 OR B lactam (IV or IM) Table Doxycycline (IV or oral) Table 2.10 OR if less than 65 with no Risk Factors for Drug Resistant Pneumococcus (see data element) Macrolide monotherapy (IV or oral) Table 2.5. The performance measure is explicitly based on the antibiotic recommendations found in Table 7 of the IDSA/ATS 2007 guidelines for community-acquired pneumonia. The antibiotic table can be found at the following address in the PN-6 MIF: me=qnetpublic percent2fpage percent2fqnettier2&c=page Blood Culture Collected Pt admitted through the ER on 04/02 at 0105 to an OBSERVATION BED. The actual admit to inpatient orders were not written until 04/03/09. The BC was drawn on 04/02 at This was before the inpatient orders but not in the ER. I chose #2. Is this the correct response? For the data element Blood Culture Collected admit to observation is considered an admit order. Blood Cultures drawn after that abstract as value 2. PN FAQs Page 3 of 11

4 Regarding Blood cultures for Pneumonia patients. I have a chart where Blood cultures were done on 827 pm. There is a physician order that says to admit the patient on 1105 pm. The 1st page of our ED record is called the triage and order sheet and says time admitting notified was 825 pm. Is time admitting notified acceptable for admission time? If so then I would I abstract Blood cultures done after admission. If this terminology is not acceptable then I would abstract blood cultures done in ED, correct? For the data element Blood Culture Collected the time of admission is based on the time the physician/apn/pa order was actually written. Since the blood cultures were drawn at 8:27 PM and the physician order to admit was written at 11:05 PM, this will abstract as value 1: Blood Culture Collected in ED prior to admission order. Blood cultures were drawn in the ED. By coincidence, the phlebotomist draws the first set of cultures at the same time that the physician dates/times the admission orders - both at Since the blood cultures were neither prior to, nor after the admission orders were written, I don't know how to answer this question. Please advise. For the data element Blood Culture Collected this will abstract as value 2. The reason for wanting to know if a BC was prior to or after the physician order to admit is for PN-3b (BC prior to ABX in the ED). The IDSA/ATS Guidelines say that BC's do not have to be drawn on every patient that comes through the ED BUT if a physician decided to perform a BC, it must be prior to the initial hospital abx. We look at physician admit order, as at the time of admit, the ED doc is basically saying, she has completed her exam and its time to move the patient to IP status to another physician's care. Chest X-Ray Chest x-ray on admission: H&P reads "...presents to the Emergency Department with his wife..." This patient was never seen in our ER - direct admit. Physician states on the H&P, "chest x-ray in the outpatient setting shows left lower lobe pneumonia." The only chest x-ray in our chart was from a few days after admission, with no inclusion terms. No other mention of chest x-rays throughout the progress notes. Physician only states, "left lower lobe pneumonia" every day on the progress notes. Discharge summary reads, "The patient was admitted to the hospital from the Emergency Department because of progressive fatigue and weakness. He was found to have left lower lobe pneumonia on chest x-ray and examination." What value should I select for chest x-ray on admission? PN FAQs Page 4 of 11

5 For the data element Chest X-Ray this will abstract as value 1 since there is documentation of an inclusion term associated with a CXR. Since the discharge summary specifies the patient was admitted from the ED and the Chest X-Ray found pneumonia, we can assume this was done the day of or the day prior to arrival. Abstraction-CXR completed on admission: Findings-The patient is status post median sternotomy. There is asymmetric elevation of the left hemidiaphragm unchanged from the previous study. No acute lung parenchymal infiltrates failure or effusions are seen. Impression: The patient is status post median sternotomy. There is persistent asymmetric elevation of the left hemidiaphragm. No acute lung parenchymal infiltrates are identified. Would this Abstract with option 2 on abnormal CXR anytime during hospital stay? For the data element Chest X-Ray this will abstract as value 4. Per Notes for Abstraction: If the only documentation of an Inclusion is prefaced with wording such as "no significant" or "no definite", select "4" (do NOT reference Appendix H, Table 2.6). Chest X-Ray": The radiology report states "...Hyperinflated lungs bilaterally with subtly flattened diaphragms is consistent with emphysema. There is bronchiectasis adjacent superior aspect of the left hilum..." Would this be value 1 or 2? For the data element Chest X-Ray since no inclusion terms were documented this will abstract as allowable value 2. The radiologist does not include any inclusion terms. The ED physician stated "no obvious pneumonia, but increased bronchial marking". Would I answer the question with a "2" neg CXR/CT? This will be a value 1. The 'increased bronchial marking' would be synonymous to the Inclusion term 'increased lung markings'. Comfort Measures Only Documentation of comfort measures on day 2 and later changed to aggressive measures because the family misunderstood what comfort measures meant? Should this be answered as comfort measures only? This will be a value 2 since this was the earliest day an inclusion term was documented. Per Notes for Abstraction: If any of the inclusions are documented, select "1," "2," or "3" accordingly, regardless of other documentation. PN FAQs Page 5 of 11

6 This patient has the following order: Palliative Care for Family Support. Would this count since it is for the family and not the patient? Care was not altered for the patient as they were only 49 years old and all care was given until she could not be resuscitated. (I know Palliative care is an inclusion term, but is it different when the context is towards the family?) For the data element Comfort Measures Only this will abstract as yes. Per Notes for Abstraction: If any of the inclusions are documented, select "1," "2," or "3" accordingly, regardless of other documentation. Would "withdrawal of care" be accepted as comfort measures? This would not be documentation of Comfort Measures Only. For purposes of this data element, only the terms found on the inclusion list are accepted. Compromise PN/compromised. CT conclusion "concerning for malignancy" and progress note "Follow up to exclude cancer emphasized". Are these statements enough to answer "yes" to compromise element? This will be a No to Compromised. For the data element Compromised, the Inclusion list is not specified as all inclusive, but the intent is to accept only those conditions in the inclusion list. The specific types of cancers in the inclusion list are the specific ones the National Pneumonia Expert Panel feel cause the type of immune suppression we are looking for in patients that need to be excluded from the Pneumonia population. Even though the inclusion list is not all inclusive we are encouraging the hospitals to consider this as an all inclusive list. For Q discharges, if MD documents "will check HIV serology," is this sufficient to answer "yes" to Compromising Condition? For the data element Compromised this will abstract as yes. Documentation of suspicion of HIV would abstract as yes. Diagnostic Uncertainty Would the following quote from ED report qualify for PN on arrival, and/or diagnostic uncertainty, "Assessment: Still not clear if patient suffering from COPD exacerbation due to pneumonia versus CHF or a combination thereof. Will treat with antibiotics and call Internal Medicine. PN FAQs Page 6 of 11

7 For the data element Diagnostic Uncertainty this will abstract as a No. This is documentation that the patient's clinical picture was questionable, unclear or not suggestive of pneumonia, but there must also be documentation that this caused a delay in the diagnosis of pneumonia at the time of admission. Healthcare Associated PN Healthcare associated pneumonia" question: If there is no documentation about an acute admission for 2 or more days within the past 90 days prior to the admission for pneumonia, but your hospital visit system and abstracting system indicates there is, can you answer "Yes" to the question regarding "Healthcare associated pneumonia"? Keep in mind, if this chart is requested by the CDAC would they be able to tell there was an admission within the last 90 days? You will use just the documentation you would send the CDAC should they request this chart. Regarding Healthcare Associated Pneumonia: If the patient has a trach and/or is on a ventilator but is cared for by family at home, is this considered healthcare associated or only if a healthcare worker is tending to the patient? This will abstract as No. In order to select yes for the data element Healthcare Associated PN there needs to be documentation that the trach or ventilator care was provided by a healthcare professional within the last 30 days. ICU Admission or Transfer A patient admitted through the ED with pneumonia. Admitted to a modified care unit and on same day of admission suffered a cardiac arrest, and was transferred to the ICU because of the cardiac arrest. Is this a YES or NO to the question for the transfer to the ICU. This will be a No to ICU Transfer since the patient was not transferred due to pneumonia or complications of pneumonia. Identified Pathogen If a gram stain came back (in the allotted time frame) sputum --gram positive cocci", would this constitute a "Yes" or "No" to the element "Identified Pathogen? PN FAQs Page 7 of 11

8 For the data element Identified Pathogen, you would need to see documentation of an organism. The results of a gram stain cannot be used for this data element unless a specific pathogen is listed. The physician must have the results of a specifically named organism within 24 hours to answer "yes" to the data element. Blood cultures drawn after arrival at the hospital almost never provide an identified pathogen within 24 hours. You cannot use the gram stain results because this does not identify the pathogen with certainty. Physician documents antibiotics for community acquired pathogens including mold. Is this (mold) sufficient for an identified pathogen? For the data element Identified Pathogen this will abstract as a No, as there is no pathogen identified. Md notes in H&P hospital for neutropenic sepsis with staph bacteremia" would this be yes or no to identified pathogen? For the data element Identified Pathogen, this will abstract as a Yes. ANY pathogen that is documented by a physician within 24 hours of arrival would result in a Yes. However, if it is a pathogen documented within 24 hours of arrival, that is not physician documentation, it must fall into one of the following categories in order to merit a Yes: Known positive culture (blood, urine, sputum, wound, etc.) Positive urinary antigen test for Streptococcus pneumoniae or Legionella pneumophilia Positive Polymerase Chain Reaction (PCR) test for Legionella pneumophilia Initial Blood Culture Collection Time I have a pneumonia case where the patient came in the ED and the doctor did not order a blood culture. The RN drew a blood culture and documented that it was drawn at 0930 and are awaiting results. When the lab was contacted they no longer had the culture and did not log it into our lab results. May I use the documentation for Blood cultures collected at 0930 or would I have to use no blood culture collected (4)since the doctor did not order it? You will use the 0930 time since a blood culture was performed, as we don't use orders for this data element. PN FAQs Page 8 of 11

9 Pneumonia Diagnosis: ED/Direct Admit A telephone order for admission was called in and included pneumonia as the admitting diagnosis. However, the telephone admission order was never countersigned by the physician. Can this order still be utilized to answer yes to pneumonia diagnosis? For the purposes of the PN measures, a called in order would be in effect even if not signed by the physician. This can be used to answer yes to pneumonia diagnosis. PN record...on the ER record under final diagnosis, pneumonia is crossed out of the final impression for the admit. Do I record a 3 for no documentation of pneumonia because of the crossing out of the inclusion term or 4 for UTD? If there is another diagnosis, this will be a value 3. Keep in mind, the only time you would use a value 4, per this Note for Abstraction, 'Only select 4 if there is a place in the ED chart to document the final ED diagnosis/impression and this area is left blank. However, if there are multiple areas to document the final ED diagnosis/impression and any are completed, do not select 4." Pneumonia For the direct admit patient is the first progress note an acceptable source for the diagnosis of pneumonia on admission? The MD admit order does not contain a diagnosis of pneumonia. The first note is the next day and is a progress note with pneumonia as a possible diagnosis. ONLY if it is an admitting note (mentions a reason for admission). For a direct admit if you find no admit note with a diagnosis, you will select value 3. What do I select for admitting diagnosis of Pneumonia when the Impression/Diagnosis line of the ED Record states infiltrate but the ED admitting order says Pneumonia, Aspiration. Since aspiration PN is listed as an admitting diagnosis, this will be a value 3. We do not want patients with aspiration PN included in the measures. If a patient is admitted via the ED, but there is not final ED dx or impression, but in the body of the ED physician notes, the ED physician documents possible pneumonia. Can I abstract #1? PN FAQs Page 9 of 11

10 This depends on the documentation but usually, if pneumonia is not listed as a final diagnosis, select value 3. If the documentation is just assessing if the differentials are appropriate- No because this would be considered a differential diagnosis. If the documentation is stating pneumonia is a diagnosis and the plan for treatment, Yes. Pseudomonas Risk Our Pneumonia Antibiotic Admission Order has a section labeled Pseudomonas Suspected. Under this section are several antibiotics listed that can be checked if given. If an antibiotic is checked under this section, are we able to answer "yes" to pseudomonas risk? No, this will not be sufficient. This check mark tells us that the physician wants to administer these antibiotics, not why. Risk Factors for Drug Resistant Pneumococcus Pt. received rocephin in the MD office prior to arrival. Would this be "Yes" on Risk factors for drug-resistant pneumococcus? For the data element Risk Factors for Drug Resistant Pneumococcus this will abstract as Yes. Any systemic antibiotic therapy in the last 3 months prior to arrival will abstract as Yes. Pneumonia patient, quesiton concerning Risk Factors for Drug-Resistant Pneumococcus, h/p has history of Arthritis/ Gerd/Hypertension would any of these be considered Drug Resistant Pneumococcus co-mobidity? Medical co-morbidities are defined as: Renal, heart, lung or liver disease documented within the last 3 months, Malignancies documented within the last 3 months, or any documentation of diabetes mellitus or asplenia. GERD and Arthritis are not medical comordiities for this element. A history of HTN will abstract as No, unless there is documentation, it is currently present. Vaccination Patient had the influenza vaccination at the end of September Documented in chart Yes, had the vaccination September Would this abstract as "received the vaccination this flu season?" For the data element Influenza Vaccination Status this will abstract as value 2. The current flu season begins when this season's flu vaccine is made available to the public. PN FAQs Page 10 of 11

11 Pt did not receive PN vaccine. On vaccine assessment sheet, nurse documents "do not give per Dr. S.". No other reason documented. Pt is taking Methotrexate and Humira for rheumatoid arthritis. Would this count to answer #4 for PN vaccination status? Or would it be #5? This will be a value 5 and the case will fail the measure. The only reasons to select value 4: the patient has a documented allergy to pneumococcal vaccine, bone marrow transplant within the year OR currently receiving a scheduled course of chemotherapy or radiation during this hospitalization. Flu vaccine administration- On the MAR, the nurse documents flu vaccine not given with comment-"not in stock". However, page 2 of 4 of the pt's D/C instructions states "These are the immunizations you received while in the Hospital: Pneumovax and Influenza". Page 4 of the D/C instructions is signed by the D/C nurse. Do I use value 1 or value 6? For the data elements Pneumococcal Vaccination Status and Influenza Vaccination Status both will abstract as value 1. For the Influenza Vaccination, documentation of "not in stock" would abstract as value 6. However, per the Notes for Abstraction: In situations where there is documentation that would support more than one of the allowable values, 1-4, select the smallest number. These FAQs have been taken directly from the Quest system and may contain words or acronyms that are not recognized by the Read Out Loud function in Adobe. If further clarification is needed, please submit a question to Quest and reference the FAQ document and question topic. Disclaimer: This material was prepared by Oklahoma Foundation for Medical Quality, the Medicare Quality Improvement Organization for Oklahoma, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy OK-0110 PN FAQs Page 11 of 11