Understanding the Pneumonia CMS Core Measures

1. Developed by Kathy Wonderly RN, BSPA, CPHQ Performance Improvement Coordinator Developed: September 2009 Most recently updated: October 2013 Understanding the Pneumonia CMS Core Measures

2. Learning Objectives • To recognize the indicators included in the CMS Pneumonia Core Measure Set. • To understand the importance of the timing of testing and appropriate treatment for the pneumonia patient. • Note: January 1,2014- September 30, 2014 changes are in italics.

3. An Overview • The core measures for pneumonia patients focus on timeliness for the start of testing and correct antibiotic selection . • To address these categories there are 2 major indicators, blood culture before antibiotic and appropriate choice of antibiotic.

4. Blood Cultures Before Antibiotics Are Started • The standard of care for any patient having blood cultures ordered is the blood cultures must be drawn BEFORE the antibiotics are started to assure that any bacteria present in the patients’ blood is identified.

5. Blood Culture • CMS has retired this measure from their data collection, however each hospital should follow their plan of care for pneumonia patient • The Joint Commission still requires that patients transferred to or admitted to an ICU have blood cultures performed within 24 hours prior to or after the arrival at the hospital. • Excluded from this indicator are patients transferred to ICU from another facility.

6. Blood Cultures • The order for blood cultures is practitioner driven but confirming they are done prior to starting the antibiotic is a nursing function.

7. Blood Culture Documentation • Be sure the time of the blood culture draw is in the medical record. Many facilities have found the time the lab enters the request is the only documentation and is often after the antibiotic start time. • If the blood culture is ordered but cannot be obtained due to dehydration, patient refusal or if the specimen is contaminated after the draw, this information must be documented in the medical record.

8. Antibiotic Measure Change • While no longer a CMS measure after 1/1/2012, it is still the standard of care to initiate antibiotics as soon as possible once the diagnosis of pneumonia has been made. • Follow your Hospital policy regarding the timeframe for the start of the first dose of antibiotic ordered to treat any infection.

9. Antibiotic Measures Selection • The next indicator for the pneumonia patient is the selection of the most appropriate antibiotic. This is a practitioner driven measure. • For the non-ICU patient the current guidelines recommend one of the following treatments:

10. Non- ICU Antibiotic Protocol 1. A B-lactam (IV or IM) such as ceftriaxone + a macrolide (IV or PO) such as erythromycin or 2. An antipneumococcal quinalone (IV or PO) such as levofloxacin or 3. A B-lactam (IV or IM) + either doxycycline (IV or PO) or 4. Tigecycline (IV)

11. Antibiotic Administration • If the patient is in ICU the recommendations are somewhat different. • They include combinations of B-lactam drugs, macrolides, antipneumococcal quinalone , doxycycline and/or an aminoglycoside. • There are several different combinations of antibiotics that are effective. The important thing is that ICU patients must always be covered by two antibiotics from different drug classes.

12. Non –ICU Patients with Pseudomonal Risk • Antipneumococcal/antipseudomonal B-lactam + antipseudomonal quinolone or aminoglycoside or Macrolide. • Aztreonam IV or IM + antipseudomonal quinolone or aminoglycoside. • Azetreonam IV or IM + Levofloxacin

13. Antibiotic Administration • It is the responsibility of the practitioner to choose the most appropriate treatment regime for each patient . The pharmacist can help the practitioner with this selection.

14. Multiple Infections • CMS understands that having multiple infections often requires antibiotic therapy beyond the recommended treatment of pneumonia .

15. Multiple Infections • To help the practitioner select the most appropriate antibiotic, a copy of all cultures done on the pneumonia patient anytime within a week prior to arrival must be placed on the medical record. • These reports as well as practitioner documentation will provide the necessary information to confirm that a bacterial infection outside the respiratory tract was present on admission (POA).

16. Smoking Cessation Change • CMS has retired the smoking cessation indicator for pneumonia patients, however it is a global measure for The Joint Commission for all hospitalized patients.

17. In Closing • Pneumonia is a year-round reason for admission and accounts for more than 4.5 million Medicare inpatient hospital days a year. • Meeting the indicators for pneumonia is very dependent on nursing direction.

18. Test Your Knowledge • To be sure to get accurate culture results the blood cultures must be drawn before the first dose of antibiotics is given. A. True B. False

19. Test Your Knowledge 2. All patients admitted with a diagnosis of pneumonia should receive the same antibiotics. A. True B. False

20. Test Your Knowledge 3. Pharmacists can play an important role in helping the physician select the correct antibiotic for his/her patient . A. True B. False

21. Test Your Knowledge 4. If the patient has multiple infections the physician must document these infections in the medical record. A. True B. False