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QUALITY OF CARE:

Tap This 3-Pronged Pneumonia Prevention Plan

Published on Sun Feb 15, 2009

Stave off this potentially lethal condition with the right clinical know-how.

Nursing homes sometimes miss common risks that set their residents up for pneumonia, which leads to poor clinical outcomes, not to mention survey deficiencies.

The good news: A combination of simple clinical strategies can rein in your facility's pneumonia and rehospitalization rates -- and put you a step ahead of Medicare's growing efforts to hold providers accountable for avoidable problems.

Prevention Is Your Best Bet

Making sure residents receive the pneumococcal polysaccharide vaccine -- and a booster, if needed -- helps stave off pneumonia due to Streptococcus pneumoniae. This strategy not only protects residents from infection but also pumps up the facility's immunization quality measure reported on the Nursing Home Compare Web site (for a review of who should receive the vaccination and when, see p. 28).

"You can give the pneumococcal vaccination any time and capture it on the MDS," as there is no specific time frame for doing so,unlike coding the flu vaccination, says Rena Shephard, RN, RACMT,MHA, C-NE, president and CEO of RRS Healthcare Consulting in San Diego. "Some people read the instructions for coding the flu vaccination and may think the two (flu and pneumococcal vaccination) somehow overlap -- but they don't," she adds. "The instructions for coding each item stand alone, as is true for all items on the MDS," Shephard says.

Resident on palliative or hospice care? "There is absolutely a role for flu immunization and even pneumococcal vaccinations in hospice," says Mary Lynn McPherson, PharmD, BCPS, professor and vice chair in the Department of Pharmacy Practice and Science at the University of Maryland in Baltimore.

Improve Residents' Oral and Dental Health

A pneumonia prevention kit should include a toothbrush, floss,and regular dental care. Why so? "One of the major causes of pneumonia is aspiration which relates to problems with swallowing -- and there's a link between poor oral health and pneumonia," says Susan Levy, MD, a medical director in Baltimore, Md. (For a free copy of a Long-Term Care Survey Alert article on best practices for managing dysphagia, e-mail the editor at KarenL@Eliresearch.com.)

Subacute care tip: Patients on ventilators should receive oral care every four hours, which has been shown to reduce the incidence of ventilator-associated pneumonia,says infection control expert James Marx, RN, MS, CIC, in San Diego.

Good idea: Occupational therapy or restorative nursing can help someone improve his oral health, advises Elisa Bovee, an occupational therapist and director of education and training for Harmony HealthcareInternational in Topsfield,Mass. For example, gum flossers available today allow a patient to hold a plastic handle with a small piece of floss suspended in between, she notes. "Residents can also put the toothbrush handle in a formation of Thera Putty to provide a better grip." Once a resident learns to use these simple devices, the CNA can supervise the person's oral health care, Bovee says -- a tactic that reduces staff time and promotes the resident's independence.

Prevent Hypostatic Pneumonia

If a resident is immobile for any reason, the care plan should include turning and repositioning to prevent not only pressure ulcers but also hypostatic pneumonia, says Patricia Boyer, MSM, RN, NHA, president of Boyer & Associates LLC in Brookfield, Wis. "The plan should also include coughing and deep breathing." And make sure to implement it right at admission, she adds.

"Hydration would also be part of the plan of care," says Boyer,noting that dehydration increases the viscosity of secretions, making it harder for the resident to cough them up. Also ask why a person is immobile or staying in the bed most of the time. No one should be in the bed all the time unless there's a good reason, such as end-of-life care or a temporary situation after orthopedic surgery, as examples,says Boyer.

Coding and care plan tip: A turning and repositioning program coded at M5c is really related to skin care, Boyer says. "But if the care plan calls for this intervention to prevent hypostatic pneumonia, then the intervention should also be documented on the care plan related to the respiratory system," she adds."Immobility causes a lot of problems, including muscle atrophy, incontinence, etc. The care plan should address all of the potential problems."

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