gram negative pneumonia

Unknown

I have attempted to educate the hospitalists at my facility on the documentation of "gram negative pneumonia" or even "possible gram negative pneumonia" but have not gotten very far. Their response is that they do not know the organism. They are however very consistant in documenting healthcare acquired and community acquried pnuemonias. Sputum/respiratory cultures are few and far between due to their lack of accuracy. Does anyone have any good references I could use to support my plea?

Thank you for your help!
Lisa McLuckie, RN
Clinical Documenation Specialist
Wooster Community Hospital
lmcluckie@wchosp.org

digardsk

I usually start with the rationale that they used something to base their antibiotic selection on...so what are they covering???

>>> CDI Talk 5/10/2011 1:27 PM >>>

I have attempted to educate the hospitalists at my facility on the documentation of "gram negative pneumonia" or even "possible gram negative pneumonia" but have not gotten very far. Their response is that they do not know the organism. They are however very consistant in documenting healthcare acquired and community acquried pnuemonias. Sputum/respiratory cultures are few and far between due to their lack of accuracy. Does anyone have any good references I could use to support my plea?

Thank you for your help!
Lisa McLuckie, RN
Clinical Documenation Specialist
Wooster Community Hospital
lmcluckie@wchosp.org

kmckaig

Our hospitalists or other doctors will often document use of "antibiotic coverage for resistant organisms" or "triple antibx coverage". We use that as part of query for "what are they treating?" Also, we look for other identifying criteria to base a query, ie. NH resident, failed outpatient, immunocompromised, etc. We often get possible, probable or suspected. Hope this helps!

sharon.cole

Our facility is consistently low in that area as well. We've spoken with our hospitalists, infectious disease guys and other groups. They will verbalize that what they are treating is most likely a gram negative organism when they say HCAP but none are willing to document that without evidence even though the patient is responding to treatment geared towards the gram neg.

Sharon Cole, RN, CCDS

Unknown

A suggestion may be to engage the physician in a discussion of the merits of documenting the specificty of pneumonia, to include the advent of the Value Based Purchasing Program for physicians to be implemented in the not too distant future. This program will include measures of physician efficiency, costs, value and outcomes that ultimately will impact the physician's reimbursement. Also, the higher the complexity of managaing a patient's clinical condition, the potentially higher level of physician medical decision making and the medical necessity for billing the chosen level of E & M service justified by the amount of physician work performed.

Hope this helps

Unknown

Coding guidelines state there does not have to be a positive sputum culture
for the physician to render his opinion. I usually will make note of
several things--vital signs on admission, WBC on admission, was this a case of
failed outpatient therapy, does the patient have a chronic condition which
will strengthen the probability of a gram negative pneumonia (COPD,
neoplasm, CHF, etc.) and the drugs used to treat the pneumonia. I will query for
the physician's opinion about the organism that is being treated. In my
physician's presentations for pneumonia, I always emphasize and teach the
concept of the physician rendering an opinion. I also will not query for gram
negative pneumonia with the first review. I will wait and note how long the
patient is on IV antibiotics. Why? In recent years, hospitals had to pay back
a lot of money for the over documentation and coding of the DRG equivalent
to 177, 178 and 179-- if they are on IV antibiotics only one day and then
switched to PO antibiotics, it was probably not a gram negative pneumonia.


In a message dated 5/10/2011 4:31:38 P.M. Eastern Daylight Time,
cdi_talk@hcprotalk.com writes:


I have attempted to educate the hospitalists at my facility on the
documentation of "gram negative pneumonia" or even "possible gram negative
pneumonia" but have not gotten very far. Their response is that they do not know
the organism. They are however very consistant in documenting healthcare
acquired and community acquried pnuemonias. Sputum/respiratory cultures are
few and far between due to their lack of accuracy. Does anyone have any good
references I could use to support my plea?

Thank you for your help!
Lisa McLuckie, RN
Clinical Documenation Specialist
Wooster Community Hospital
lmcluckie@wchosp.org

robert.hodges2

Have you asked them simply what type of pneumonia they are treating? That's what I do here. I've also done a lot of education and one on one talks with providers that you don't have to have a positive culture to treat, which they all agree with by the way. I have gotten them to use probable or possible bacterial pneumonia a lot. I don't know if you'll ever get the gram negative specificity, but I'd reinforce to them to document what they are treating or what they suspect. That way you get a better grasp to justify the resources being used to treat the pneumonia, the severity of illness, and the risk of mortality. They should care about that. Also remind them that if cultures come back later with something more specific, then they can update their diagnosis. Just remember, over 60% or pneumonias will have a negative blood and/or sputum culture.

Robert

Robert S. Hodges, BSN, MSN, RN, CCDS
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
 
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
 

sharon.cole

My physicians will TELL me they think they are treating a gram negative but without proof, they WILL NOT document. Our queries include several risk factors, v/s, type and length of antibiotics, even when they change or add antibiotics and the fact that they are documenting that the patient is now improving with change or addition of certain antibiotics. They will document Sepsis due to HCAP before they will give a probable gram negative PNA diagnosis.

Sharon Cole, RN, CCDS
CDI Specialist
Case Management Dept
Providence Health Center
254.751.4256

Unknown

We have also had resistance with this documentation. We did a newsletter educating about types of pna. We have tried one on one teaching, met with the ID docs---all to no avail. I don't understand the resistance. We even have a decision tree to help the doctors understand the documentation. It's like hitting our heads against a wall!

mary.a.dunn

The decision tree is very helpful . Thank you for sharing. I would be interested in your Newsletter about pneumonia if you would be willing to share. That is a great idea.
Mary.a.dunn@comhs.org
Thank you,
Mary

robert.hodges2

I do like the decision tree too. Thanks for sharing.

Robert

Robert S. Hodges, BSN, MSN, RN, CCDS
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602

Unknown

The newsletter is basically the decision tree with a couple of lines explaining classification and that cultures aren't needed. I have attached it.

kmckaig

Thanks for sharing that decision tree.

I am interested in knowing what type of education has been most successful with the docs. ie. one on one, groups, newsletters, posters etc.
Thanks, Karen


Karen McKaig, BSN, RN, CCM, CPUR
Case Manager
Clinical Documentation Specialist
Baxter Regional Medical Center
Mountain Home, AR 72653
870-508-1499
kmckaig@baxterregional.org

Unknown

Love the tool!!
Thanks so much for sharing. Do you have a similar decision tree for any
other disease process and documentation?
Thanks so very much!

Tina Simpson, BSN, RN, CCDS
Clinical Documentation Specialist Coordinator
White River Medical Center
1710 E Harrison St
Batesville, Ar 72501
870-262-3825 / fax 870-262-6571
tsimpson@wrmc.com

catladyrn

Very nice decision tree. Gm neg pna is always a challenge. I usually err on the side of caution when considering a query.

Renee


Linda Renee Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center

Unknown

Thank you everyone for all of the great feedback and thank you Gina for
sharing your decision tree! I feel better knowing I'm not the only one
battling this issue and feel more comfortable going back up to bat to
address this dx.