Preventing Pneumonia Readmissions

Strategies for preventing and reducing pneumonia using adherance monitoring and feedback.

This material was prepared by Health Services Advisory Group (HSAG), a Quality Innovation Network-Quality Improvement Organization (QIN-QIO) under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS). Views expressed in this material do not necessarily reflect the official views or policy of CMS or HHS, and any reference to a specific product or entity herein does not constitute endorsement of that product or entity by CMS or HHS. Publication No. QN-12SOW-XC-01102024-02

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Care Coordination Series, Season 1, Episode 6: 
 Preventing Pneumonia Readmissions 

[00:00:00] Hello, everyone, and welcome to today's care coordination quickinar. Today, we're going to be talking about preventing pneumonia readmissions. I have my colleague, Karen Verterano, who's a MSNRN quality improvement specialist with HSAG, and she's going to be presenting on that: preventing pneumonia readmissions.

So, pneumonia is one of the most common healthcare- associated infections in SNFs, occurring in an estimated 1 to 2 residents for every 1, 000 days of nursing home residence. It is a significant cause of mortality and morbidity among residents in the skilled nursing facilities, and deaths as a result of pneumonia can be as high as 40%.

Risks for factors for the pneumonia now, higher risk and skilled nursing facilities include those who are 65 years or older, smokers, even those who recently quit, residents with brain disorders, [00:01:00] including head injuries, stroke, dementia, Parkinson's, and Alzheimer's. Those who have had HIV, on chemo, or on steroids for long periods of time, as these residents will definitely have a weakened immune system, chronic lung condition.

And then we have diabetes, heart failure, residents who are receiving enteral feedings, those who are malnourished. Residents that are bedridden, who are not active residents, who have been recently hospitalized. And last, those residents who are not able to perform oral hygiene or have oral hygiene assisted in the proper manner.

So, assessing for pneumonia, what are we going to look for? Well, residents may have a fever, chills, sweats, exhibit fatigue. They may be tachycardiac or have that high heart rate, greater than 100, lower than normal body temperature, and they can have pain in the chest area. This discomfort [00:02:00] may occur with normal breathing, or they may have a cough, which can be productive, nonproductive with the clear yellow, yellowish, green, or blood tinge sputum.

The resident may experience the increased pain when coughing. So, at rest, just normal breathing, they may have that discomfort and with coughing, it may be more intense. Residents can be more short of breath at rest or even with minimal activity, getting up to go to the restroom or even getting up to sit in a chair they may get short of breath. They may become confused and have loss of appetite. And we know that no two residents are going to appear the same. So, one resident may appear with a fever fatigue. Some symptoms may be very mild. Some may stand out. So, we always have to be mindful. Any change in that condition is something that we want to pay attention to.

These are the complications that we may see after the pneumonia, which is so important, why it is so important to prevent it: Pulmonary fusion, respiratory failure, lung abscess, [00:03:00] kidney, heart, or liver damage, inflammation of the lining of the heart (which we know as pericarditis), atelectasis, or collapse within the lungs, and sepsis. So, they may have one of these, multiple of these conditions. So again, why it's so important to identify those risks and prevent and do anything to prevent the condition as much as possible.

So, now, let's take a deeper dive into pneumonia progressing to sepsis. The most common cause of sepsis is community- acquired pneumonia. Sepsis is a type of an infection in the respiratory tract that leads to a systemic response to infection, meaning it goes through the whole body. Therefore, early diagnosis and treatment of pneumonia is critical and vital and most important. All residents with pneumonia should be monitored for sepsis. This can be a gradual process, or they can become septic very, very quickly in a matter of an hour, several hours.

So, you want to check their [00:04:00] temperature regularly for a fever or low body temperature. They may have chills or the rapid heart rate—again, that difficulty breathing or dyspnea. You may notice a skin rash. The residents may become confused or disoriented with any change in condition. And now we know if the resident is normally confused, this is something that we may not be as cautious with. We just want that change in that confusion or increased in that disorientation. And then, if they experience a sudden drop in their blood pressure, they will most likely become lightheaded as well. And so, for these reasons, again, pneumonia and prevention is so important. 

So, what can we do to prevent pneumonia? First and foremost, of course, are the vaccinations. Not only the pneumonia vaccine, right? But evidence shows that the flu and Covid vaccines at the very least will lessen the severity of symptoms of pneumonia. Proper hand hygiene. We get the residents moving, walking. Active or passive [00:05:00] major range of motion if they're not able to walk down the hall. Turn the resident every 2 hours. These can all help in preventing pneumonia. 

We also want to encourage the deep breathing exercises, an adequate diet, and maintaining proper hydration. Tracking pneumonia cases in your facility and sharing adherence monitoring with staff has shown to improve outcomes. So, in other words, we need to look for those gaps, find them, find a way to identify those, and then report back so that we can change the habit and break that pattern.

So, I'm so excited to share our HSAG Pneumonia Prevention Toolkit, and the first tool is the Action Plan. It just has some demographics you can enter in there, including the name of the nursing home, and then a goal, and please make sure the goal is reasonable. So, you want to take, like, maybe 30 percent if your numbers are high. Or if you've had zero pneumonia cases in the past month, we want to maintain zero by the end of the year. [00:06:00] So, as long as it's reasonable, attainable, and reachable, then we look down at the actions. So, we want to review and update the policies and procedures to reflect the current evidence-based practices. The evaluation effectiveness of this is the 100 percent of the policies and procedures will be reviewed and updated. 

Next, we want to look at those for especially those facilities that have a large number of beds. Identify champions for areas or for units to help maybe the IP person do the audits and help with teaching the staff, the residents, and family. Maybe in a couple of weeks after we implement this action plan, we can identify some champions, get them trained to assist us. And then moving forward, we're not so underneath the water. We feel like at the end of the tunnel and the more people we get on board, the more the word gets out there, and we can improve the quality for all these residents.

Next, we want to conduct education with a teachback for staff. Even though we know this is for discharge teaching to [00:07:00] residents, it works really well with the staff. We want to include the nurses, nursing assistants. Again, you may want to include family members if a resident has a family member in there that wants to take part in their care.

The list here includes the pathophysiology of pneumonia, clinical signs, risk factors, prevention bundles, and these are all tools that are available to you so that you don't have to reinvent the wheel, so to speak, and we have the presentation, this presentation, and other quickinars that you can use to educate your nursing staff and nursing assistants that are short and doable.

So, again, the responsible person would be yourself, or maybe your DSD, along with IP, maybe your champion can take over some of these educations, so any new employees that we have coming on, and then annually, for the annual education and signing off on that. And of course, we want 100 percent of the staff to receive that education for the pneumonia and prevention bundles.

Next the risk form to identify residents that [00:08:00] are high risk, followed by implementation of the prevention bundle, and then the HSAG Pneumonia bundle compliance tools to prevent strategies. Now, as far as the responsible person or persons for these, I highly recommend that, again, you… one person doesn't take this all on as a task, that we involve maybe the staff nurses and get that risk form to be a part of the admission packet. So, that when that nurse is admitting the new resident to the facility, check off that assessment form, and then it will be completed, and then let the IP or somebody else know who was identified as a high-risk person, so that we know and then we can start with the next prevention bundle, and put that into place. So, as far as the percentage of residents screened, I highly recommend that you just start with new residents coming into the building, and then roll it out to the seasoned residents. We're just starting to implement it slowly. Take baby steps until we get this across the whole SNF building. [00:09:00] 

And then, residents that had the implementation of the pneumonia bundle, again, I recommend we start with 100 percent of the residents that were screened that had an identified as high risk that we implement that pneumonia bundle. As far as audits, this depends on if you have champions, if you're doing it yourself, maybe start with a small number. If you're building is not very large, like three. And then, build up to five a week. And our compliance goal, I like to encourage that we maintain 85%. Try not to go any lower than that.

The next piece of the toolkit is the risk factor for pneumonia. This is the one-page screening tool to identify residents most at risk for developing pneumonia. This is the one that I mentioned earlier, perhaps you could put in your admission packet. So, when your admission nurse is filling out their assessment, they can just check this off and let the IP, DON, somebody know or put it in the chart, in the record for the physician, and they can see who is at risk for pneumonia. [00:10:00] They can let the CNAs know they can get them involved. So, when we get those new admissions into our building, we don't want to be held responsible if that resident comes to us with pneumonia. We want to be aware of that. Because first of all, we don't want them to be a readmission back to the hospital. Secondly, we don't want them to get worse and end up septic. 

This is the pneumonia bundle risk action tool that I mentioned earlier as well from the action plan. So, if you'll notice, the risks are listed for you here, just as they were on the other form, but actions have been entered. So, when I'm looking at this, I don't have to go and say, okay, well, my resident has decreased activity or immobility, what am I going to use when I'm doing their care plan? We have it listed right here. 

And this is the assessment, the sign and symptom assessment tool. This is used similar to the SBAR. So, we look again, if we see the fever, lower the normal body temperature. Cough. Any of those signs and symptoms that I [00:11:00] mentioned earlier, that pleuritic pain or pain in that chest area, the shortness of breath with rest or with mild movement, confusion, loss of appetite, any change in the resident's condition should be reported immediately.

This document has also been used at facilities and given to the CNAs, and if they notice these changes, they can fill this out and report it back to the nurse immediately. And it says, if any of these are identified, the next step is to report as further testing will probably be recommended. So, the nurse can use this as a SBAR tool, like I said, to report to physicians. They can use it when reporting from shift to shift. So, a nice simple page tool that they can make as a part of the medical record as well. 

And as I spoke earlier of the pneumonia audit tool, starting maybe with just 3 or 4, depending on the size of your facility, or how many IPs, DOI, clinical people, whoever will be able to assist you with this audit, [00:12:00] we recommend that you use this like a huddle. You use this as a spreadsheet and under column 1, you see that resident 1, and then resident 2, resident 3. So, when I go down, this automatically populates as a pull-down box, yes or no. I mark the appropriate, so did staff perform hand hygiene, washed in and out? Yes. And then at the bottom of that column, where it says 87.5, seven were “yes,” it automatically populates my total adherence per patient, and then you can't see here, but it will also give me my total percentage of adherence by observation. So, how many of the staff performed hygiene in and out on how many of those residents across the columns, across the rows rather. And then on the bottom right, the second tab on this audit tool will give you the bar graph so that it gives a nice visual. So, after you do those observations, you can meet with the person you are observing with staff and say, “Hey, you know, we have some [00:13:00] opportunity here.” It's not punitive, but a tool to help us improve our processes.

This material was prepared by Health Services Advisory Group (HSAG), a Quality Innovation Network-Quality Improvement Organization under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS). Views expressed in this material do not necessarily reflect the official views or policy of CMS or HHS, and any reference to a specific product or entity herein does not constitute endorsement of that product or entity by CMS or HHS. Pub No. QN-12SOW-XC-01122024-03