What are your top challenges?

What are your top challenges in CDI?


  • Defining CAP vs HCAP, and if that CAP evolves to become known on day 2 (from mild resp symptoms on day 1, not yet visible on CXR on day 1),  how can we all accept that it is a CAP?  It is hard for a non-clinical person to understand.   And if it is a CAP, is it then POA or not POA?
    How do you help your non-clinical coders to better understand clinical concepts?
    Please share your thoughts and suggestions.
  • Hi S. Burke

    CAP stands for community- acquired pneumonia and usually develops in patients who have had no (or very limit) access to any healthcare settings, such as a dialysis center or outpatient facility for wound care. The most common pathogens associated with this type of pneumonia are Streptococcus pneumoniae, Haemophilus influenzae, and atypical bacteria and viruses. Some of the signs and symptoms you may see in this patient would be fever, cough, increased sputum production, pleuritic chest pain, dyspnea, tachypnea and tachycardia. Diagnosis is often based on clinical presentation and chest x-ray. Treatment could include antibiotics, depending on the cause of the pneumonia along with oxygen therapy. Prognosis is dependent on some variables such as the patients age, presence of other comorbidities, status of their immune system and the identification of the casual organism (some organisms are harder to kill than others.)

    Both HAP and HCAP are consider nosocomial pneumonias and often the terms HAP and HCAP are used interchangeably by providers but, hopefully the following information will be of some assistance to you

    HCAP stands for Healthcare associated pneumonia, and is a pneumonia that occurs in non-hospitalized patients who either live in a nursing home or other type of long term care facility or have undergone treatment such as chemotherapy, IV infusion or wound care, within the last 30 days, have been hospitalized in an acute care hospital for >2 days within the previous 90 days. Pathogens include the same ones you would see in CAP with the addition of gram-neg bacilli (pseudomonas aeruginosa) and staphylococcus aureus (including methicillin-resistant s.aureus) and other antibiotic resistant pathogens. Signs and symptoms that you would be looking for are the same as other types of pneumonias that occur in other settings. Diagnosis is also based on presentation and chest x-ray. Treatment would be broad-spectrum antibiotics. Often these types of pneumonias are more serious that the CAP because the patient usually has another medical issue that caused them to be in contact with a healthcare system or they reside in a nursing home which makes them at higher risk due to numerous common conditions that exist in a long-term facility.

    HAP stands for hospital acquired pneumonia.  It includes ventilator associated pneumonia (VAP), postoperative pneumonia and pneumonias that develop in unventilated patients who have been hospitalized for 48 hours. The common pathogens seen in this type of pneumonia include gram-neg bacilli, staphylococcus aureus and other antibiotic resistant organisms. Sign and symptoms would include malaise, fever, chills, rigor, cough, dyspnea, and chest pain. In ventilated patients, pneumonia usually presents as worsening oxygenation and increased secretions. Diagnosis is based on clinical presentation, chest x-ray and can be confirmed by blood cultures or cultures of pleural fluid obtained during a bronchoscopy, which make diagnosis difficult.  Treatment includes antibiotics and prognosis is usually poorer due to other comorbidities the patient may have.

    I know that is a lot of information and as you can see the diagnosis is often dependent on the patient’s presentation, and just to make sure we are on the same page diagnosis is also based on provider documentation.  As long as we are able to trace the signs and symptoms back to the time of admission the POA status of any type of pneumonia would be yes (Y), it is the cases where you cannot see any indicators that the condition exists at the time of admission that we would be expected to query the provider for clarification of the diagnosis’s status. As far as being able to teach clinical concepts to a non-clinical person, this takes time and education. I would suggest perhaps pairing them with someone who is clinical, maybe attend some of the education sessions sponsored by other departments, start with the basics and work your way up.  I have always recommended that the CDI spend a day or so with the coders and that coders spend time with the CDI staff, a better understanding of the positions will create a better team.

    I hope this information is helpful and please let us know if you need further assistance.

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