9/9/2015. Disclosure / Contact. Pneumonia Stats. Exploring the Clinical and Regulatory Impact of Pneumonia in Long Term Care

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1 Exploring the Clinical and Regulatory Impact of Pneumonia in Long Term Care Rob Shulman R.Ph. CGP FASCP Director of Consulting Services Remedi SeniorCare William M. Vaughan,RN, BSN Vice President, Education and Clinical Affairs Remedi SeniorCare Disclosure / Contact Rob Shulman has no relevant disclosures William Vaughan is a shareholder at Remedi SeniorCare, a consultant to CMS currently working on QAPI and on the advisory board of the Institute for Safe Medication Practices long term care newsletter Rob.Shulman@Remedirx.com William.Vaughan@Remedirx.com Pneumonia Stats 4 th leading cause of death in the older adult Leading infectious disease cause of death in older adult Elderly more likely to experience complications such as meningitis Annual incidence 25 44/1000 for non institutionalized pts (4x s) Increases to /1000 in residential care Mortality rate form community acquired pneumonia = 30 % Mortality rate from nursing home acquired pneumonia = % Hirth,V: Case Based Geriatrics: A global Approach. New York. McGraw Hill pp

2 Age Related Physiologic Changes Pertinent to Infectious Disease in the Elderly Rise in body temp in response to pyrogens is blunted Reduction in elasticity of lungs Reduction in respiratory muscle strength Enlargement of the Alveoli senile emphysema Blunted cough reflex Mucociliary clearance Sensitivity to hypoxia and hypercapnia Comorbidities (DM, CHF, CVD, CRF) Presentation Atypical As little as 33% elderly present with high fever Altered mental status = 20 50% Complaints of less chest pain Fewer HA s Fewer myalgias Increase in rales Fernandez Sabe NCJ, Rodon B, et al. Community Acquired Pneumonia in very elderly patients: causative organisms, clinical characteristics and outcome. Medicine 2003; 82: Common Pathogens Community Acquired: S. Pneumonia atypical bacteria viruses Hospital lacquired: P. Aeruginosa Enterobacteriaceae Long Term Care Acquired: S. Pneumonia Influenza Eneterobacteriaceae P. Aeruginosa 2

3 Antibiotics Antibiotic Prescribing Prevalence = 7 10% Range of courses of tx = per 1000 resident days 50 70% of all residents receive antibiotics in a given year 25 75% of systemic ATBs in LTC inappropriately prescribed 60% of topical ATBs in LTC inappropriately prescribed Source: April Accessed Antibiotic Resistance 2 million cases of ATB resistance in US annually Hospital stay increases from 6.4 to 12.7 days Mortality increases two fold Costs per occurrence increases by 18, Results in $20 billion per year in direct health care costs Source: P&T Vol 39 No 12 Dec 2014 p

4 Resistance Prevention Start an Antibiotic Stewardship Program! Limit ATBs for colonizations: helps prevent MRSA, VRE and C.Diff Don t treat a contamination (asymptomatic bacteriuria in catheterized pt.) Utilize appropriate antibiotics: most effective narrow spectrum Change therapy when C&S is available Non physician prescribing results in higher ATB use Track Antibiotic usage: create antibiograms Antibiotic Stewardship Programs (ASPs) Goal: optimize clinical outcomes when ATBs are used: Limit antimicrobial resistance Improve treatment efficacy Minimize drug related adverse events Reduce treatment related costs ASPs (continued) Basically a multidisciplinary committee Track facility ATB Usage vs C&S involve your RPh Create facility specific ifi antibiograms Track incidence of MDROs should decrease over time Provide education Create specific policies regarding catheter care, culturing 4

5 New Drugs Zerbaxa (ceftolozane/tazobactam) Treatment of gram ( ) infections ESKAPE pathogens: Enterococcus faecium Staphylococcus aureus Klebsiella pneumoniae Acinetobacter baumannii Pseudomonas aeruginosa Enterobacter species Sivextro (tedezolid phosphate) Treatment of ABSSSIs incl MRSA Second Generation Oxazolidinone (Zyvox = 1 st gen) Pneumococcal Vaccine Updates September 2014, ACIP recommends both PCV13 (Prevnar 13 ) and PPSV23 (Pneumovax 23 ) administered routinely in series to all adults 65 years. 65 yrs and vaccine naïve or no record of vaccination: administer PCV13 wait 6 12 months give PPSV23 Prior vaccination on or before age 65 with PPSV23: wait 12 months and administer PCV13 Prior vaccination before age 65 with PPSV23: wait one year then give PCV13 then wait 6 12 months and give a second dose of PPSV23 time between 1 st and 2 nd dose of PPSV23 should be 5 years minimum. Common Antibiotics Requiring Dosage Reductions in Renal Insufficiency Amoxicillin Erythromycin Amoxicillin/clavulanate Fluconazole Ampicillin Gentamicin & Tobramycin Ampicillin/sulbactam Imipenem Cefazolin Meropenem Ceftriaxone Metronidazole Cephalexin Nitrofurantoin Ciprofloxacin Penicillin G Clarithromycin Piperacillin Clindamycin Tetracycline Daptomycin TMP/SMX Vancomycin 5

6 Keeping the Peace What Happens when Pneumonia and Regulations Collide? Is It Nursing Home Acquired Pneumonia? Assessment Source: Alberta Health Services Diagnosis / Management of NHAP March, 2015 F 157: Notification of Changes What Significant change in status Need to alter treatment significantly Who Resident Physician ( checklist) Legal guardian or interested family member Resident can trump interested family member notification When Immediately 6

7 F 155: The Right to Refuse Treatment Informed consent Advance care planning Living will Power of attorney Limitations on treatment Right to change one s mind Hospitalization End stage conditions Resident rights versus surrogate rights F 328: Special Needs Parenteral and Enteral Fluids Pneumonia fluid deficit See F 327 sufficient fluids Tracheostomy Care Staff competency Respiratory Care Oxygen Pulmonary toilet Assessment (O2 sats, lung sounds?) Pop Quiz Federal nursing home regulations require that antibiotics be administered within what period of time after being ordered? a) 30 minutes b) 1 hour c) 4 hours d) Next shift e) As soon as possible f) None of the above 7

8 F 425: Pharmacy Services 1 st dose availability IV starts One hour before / one hour after Allergies Time to clinical improvement C diff Interim medication regimen review F 441: Infection Control Investigates Controls Prevents Line listing Resource: Infection Preventionist's Guide to Long Term Care (APIC) Education Accept / refuse Document F 334: Influenza / Pneumococcal Immunizations 8

9 F 502: Lab Service / F 508 Radiology Services The facility is responsible for the quality and timeliness of the services. Pneumonia Diagnostic pitfalls Systemic failures Timeliness Communication Follow up Nursing Home Acquired Pneumonia Regulatory Pearls Frequency/morbidity/mortality demands a consistent approach (welcome baby boomers) QAPI The push to treat in house ABT stewardship / Infection control practitioner The old man s friend advance care planning Can earlier hospice help? Remember, pneumonia is only part of the lung picture Thank you 9