Long-Term Care Survey Alert

Assessment tool for pneumonia patients can stave off QA, survey woes.

Helping residents with pneumonia avoid an unnecessary acute-care stay can save them from hospital-acquired complications that surveyors and plaintiff attorney may end up blaming on your facility.

For example, hospitalization can lead to pressure ulcers, delirium due to the change in environment and mood deterioration, notes David Mehr, MD, MS, associate professor with the Department of Family and Community Medicine at the University of Missouri at Columbia.

To help decide whether a particular resident with a pneumonia diagnosis requires hospital care, facilities can use a risk assessment tool developed by Mehr and his cohorts at the University of Missouri at Columbia.

How it works: You plug the pneumonia patient's assessment data (gender, nutritional status, lab values, ADL status, mood decline, etc.) into the tool to calculate his risk of dying  or suffering complications (morbidity).

A resident with pneumonia who scores 0 to 4 on the assessment instrument has around a 2 percent risk of dying. Those with a score of 5 or 6 have a 7 percent likelihood of succumbing within 30 days.A nursing home can safely care for low-risk pneumonia patients in many cases. "If a nursing home resident can swallow, she can often take an oral antibiotic to treat pneumonia - for example, Levaquin is a reasonable choice ," says Mehr.

"Intravenous fluids and antibiotic therapy may be required for people who can't swallow although IM injections can also work, if the person isn't dehydrated," he adds.

Avoiding IVs is important in elderly people with dementia who remove IV lines and require restraints to receive the therapy, according to Mehr. "Restraints can start a downward spiral, including risk of mood decline and pressure ulcers," he warns.

Consider Resident, Family Goals

The decision to hospitalize should also involve the resident's/ family's goals for care, observes Mehr. "For low and moderate-risk people (scores up to 8 based on the tool's scoring), the data aren't clear as to whether hospitalization helps - and it may pose significant disadvantages," he says.

Obviously if a resident is critically ill and needs a ventilator - and survival is a goal - he will require hospitalization unless the nursing home can provide that level of care, says Mehr.

"But nursing homes should work with residents and families to define care goals before the resident requires hospitalization," Mehr adds. "Some families may require a hospitalization of their loved one to realize they don't want to go down that path again."

Teaching residents/families about how people with dementia typically die can help ward off hospitalizations. "Studies of death certificates show that pneumonia is the cause of death among people with dementia 50 to 70 percent of the time," reports Mehr. That's because neurological decline causes people to become more vulnerable to aspiration pneumonia and infection.

"All pneumonia is probably aspiration pneumonia to some extent - not food, necessarily, but upper respiratory secretions," says Mehr.

"Also, as someone becomes malnourished, their vulnerability to infection increases," he adds.

Editor's note: For more information on the risk assessment, see the next story.