Pneumonia
Hello fellow CDI folk! My partner and I are looking for a couple of "catch-phrase" sentences to explain that we need the TYPE of bacteria the MD was considering as the cause of the PNA when they ordered the antibiotic treatment. Trying to do some education "on-the-fly". We have found keeping it SHORT, SWEET, SIMPLE and TO-THE-POINT is better received by our physicians.
Any helpful tips would be GREATLY appreciated!
Julie Cruz RN, CDS and Gail Eaton RN, CDS
St. Joseph Hospital
Eureka, CA
Any helpful tips would be GREATLY appreciated!
Julie Cruz RN, CDS and Gail Eaton RN, CDS
St. Joseph Hospital
Eureka, CA
Comments
Documentation guidelines suggest documenting your clinical impression of the bacterial or viral type of the pneumonia, such as gram negative, Pseudomonas, or Streptococcus pneumoniae. Also, document aspiration pneumonia when aspiration is the known or suspected etiology.
Although the acronyms “HAP,HCAP and CAP” may have significance in the clinical setting, it lacks specificity and will be reported as “unspecified” pneumonia unless the causative organism is linked to the pneumonia. Reporting pneumonia is divided between simple pneumonia (viral, pneumococcal, H. infuenzae, streptococcal, and unspecified) and complex pneumonia (Klebsiella pneumoniae, Pseudomonas, Staphylococcus, other gram negative bacteria, and aspiration). Please be specific when the patient has a diagnosis of pneumonia. If an organism is identified in a sputum culture it must be linked to the pneumonia in the documentation for reporting purposes; avoid linkage to the sputum.
Example:
Sputum + GNR, suspect gram – PNA
CxR w/bilateral infiltrates, sputum + for pseudomonas, possible pseud. PNA
Other___________.
Debbie Smith RN, CCDS
UTSW
Sent from my iPad
First thing that came to mind
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
1. Do they have sepsis? We don't typically admit many patients who only have PNA. Every admission for PNA needs careful review for sepsis criteria.
2. Then look for things that would increase severity. If they are coming in with PNA and dying it is likely they are fragile to begin with.
a. Was this aspiration PNA? Are we dealing with an atypical, difficult to treat infection?
b. Comorbidities- if these patients are dying they should have other things going on that increase SOI/ROM. Why did this patient die versus all the other PNA patients? Resp failure, encephalopathy, chronic conditions??
I review all our mortalities (and also review PNA quarterly for PEPPER) and we very rarely have a patient die with PNA as pdx. They SOI/ROM should generally be high unless these patients came in and were quickly moved to hospice or something like that. Those occurrences will happen but they should be very rare.
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
I agree that these patients should generally come with more in-depth health issues. The struggle I see is that the preliminary documentation perhaps in the ER or on admission progress note is not offering a depth of information and by the time CDI reviews the patient they have been moved to hospice or have possibly expired leaving no time to make a difference in these short stays. This is information that has been communicated to the providers regarding hospice/terminal patients in the past.
Thank you for your suggestions, I will certainly discuss these issues again with the Quality department.
Amber
If the documentation is limited from your ER and admission note, that might be an issue that CDI can help with.
If all you are seeing is symptom based documentation, there is opportunity for CDI to work with the MD's to start talking about what they are suspecting when the patient is admitted.
I agree that it is difficult when the patient comes in and immediately is started on a morphine drip. If you don't do a workup and the treatment is comfort care, than your hands are tied in that rare circumstance.
However, if the patient comes in and is admitted for one or two days and is treated with heavy duty antibiotics (such as vanc/zosyn), than by treatment alone you can almost guarantee they are treating for a suspected gram negative or mrsa pneumonia (likely because as you said your pts are elderly and coming in from snf's).
We evaluate every patient for Sepsis that presents with an infection-depending on how strict your protocol, you might be missing some opportunity here? I say this respectfully, because I know protocols are in place for a reason-but if it is too stringent, it could be hurting your data. Sirs criteria seems to be the criteria that is most widely used and accepted.
The other options as others have said is just looking to see what other organs are failing and if the patients are expiring it would be rare not to see some accompanying acute renal failure/atn, encephalopathy, and/or acute respiratory failure. In addition, the CDI can review to make sure that all other documented co-morbid conditions are coded to the highest level of specificity.
Lastly, depending on your hospital policy, even if the CDI gets to the case at the end of the stay or after the patient expires, the MD can wrap up his or her thought process in the discharge summary or in an addendum. I review all mortality reviews after they have been coded but before the bill drops and we will query the provided as needed to ensure the record is reflective of the care we provided-nothing more, nothing less: )
Thanks,
Kerry
Kerry Seekircher, RN, BS, CCDS, CDIP
Clinical Documentation Program Manager
Northern Westchester Hospital
400 East Main Street
Mount Kisco, NY 10549
Email: kseekircher@nwhc.net
Phone: 914-666-1243
Fax: 914-666-1013
Amber
Pneumonia
Please clarify the etiology / consequences of the patient's pneumonia:
Provider Query Response:*
Suspected Etiology
0 No form of PNA
0 Community-Acquired Pneumonia
0 Aspiration
0 Ventilator Associated
0 Bacterial
0 Viral
0 Fungal
0 Causal Organism***
Consequences of the pneumonia include:
0 Acute Respiratory Failure
0 Acute Respiratory Distress
0 Hypoxemia, alone
0 Hemoptysis
0 Sepsis
0 Parapneumonic Effusion
0 Empyema
0 Lung Abscess
0 Exacerbation of Asthma
0 Exacerbation of COPD
0 Exacerbation of CHF
You may answer this Query by marking the checkbox(es) above or using free text at the ( * ) if appropriate.
Query:
On (Date) documentation in the (Note Type) section of the medical record indicates the patient has pneumonia. Clinical evaluation / treatment includes***
The purpose of this query is to ensure accurate coding, severity of illness and risk of mortality compilation. When responding to this query, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
Submitted by: Paul Evans, RHIA, CCDS