Pneumonia (PN) Answer Guidance

Transcription

1 Pneumonia (PN) Answer Guidance PN Version: 3 - covering patients discharged between 01/10/2017 and present. Programme Lead: Joanne Higgins Clinical Lead: Dr B Chakrabarti advancing.quality@nhs.net Website: Produced on 30 August 2017

2 s for Pneumonia (PN) Q1. Did the patient have an abnormal chest x-ray/ct scan within 24 hours prior to hospital arrival or anytime during hospital stay? Q2. Was the patient commenced palliative care by the post-take ward round? Q3. During this hospital stay, was the patient involved in a clinical trial which directly affects the measures in this AQ CFA? Q4. Was the patient transferred from the A&E department of another hospital? Q5a. What is the earliest documented date the patient arrived at the hospital? Q5b. What is the earliest documented time the patient arrived at the hospital? Q6. What is the time the patient was discharged from acute care? Q7. Was a final diagnosis/impression of pneumonia documented in the medical record as part of A&E, MAU or post-take ward round documentation, or as an admission diagnosis/impression for a direct admit patient? Q8. Is there documentation of a reason(s) that despite being seen by the consultant (or person working as part of the consultant team), the patient s clinical picture was questionable or unclear and not suggestive of pneumonia? Q9. Was there a reason documented by the consultant (or part of the consultant team) for not performing a chest x-ray? Q10a. What was the earliest date a chest x-ray was performed on the patient? Q10a. What was the earliest time a chest x-ray was performed on the patient? Q11. Was the patient immunocompromised or taking systemic corticosteroids? Q12. Was the patient hospitalised in the last 14 days? Q13. Did the patient receive antibiotic 24 hours prior to arrival at hospital? Q14. Is there documentation a pulse oximetry was performed within 4 hours of hospital arrival? Q15. Is there documentation an arterial blood gas (ABG) was done within 4 hours of hospital arrival? Q16. What is the CURB-65 Score documented on the A&E form, MAU form or first post take ward round record at the hospital? Q17. Was the patient admitted to Critical Care/ICU by the post-take ward round? Q18. Is there documentation that the patient had a positive diagnostic test for pneumonia pathogen on arrival or within 24 hours of arrival at hospital? Q19. Was there another suspected source of infection in addition to pneumonia? Q20a. What is the name of the antibiotic administered during hospital stay? Q20b. What was the date of administration for the antibiotics? Q20c. What was the earliest time of administration for the antibiotic dose? Q20d. What was the antibiotic administration route? Q21. Did the patient receive the appropriate antibiotic regime? Page 2

3 Q1. Chest X-ray - abnormal MDE ID: Chest_X-ray_Abnormal_PN2015 ( ) Did the patient have an abnormal chest x-ray/ct scan within 24 hours prior to hospital arrival or anytime during hospital stay? Documentation in the medical record that the chest x-ray or CT scan, performed within 24 hours prior to hospital arrival or anytime during hospital stay, was abnormal. Some patients may have a chest x-ray performed prior to arrival at hospital, by their GP or in community care, therefore a negative time of up to 24 hours will pass this measure. Answers Documentation in the medical record that the chest x-ray or CT scan, performed within 24 hours prior to hospital arrival or anytime during hospital stay, was abnormal. documentation in the medical record that the chest x-ray or CT scan, performed within 24 hours prior to hospital arrival or anytime during hospital stay, was abnormal This data element only applies to x-rays and CT scans, as long as the x-ray or CT scan shows the chest or part of the chest, it can be used, for example: if Infiltrate in the chest is listed among other findings in the radiographic report of a CT scan of the abdomen, select. Both regular and portable chest x-ray results are acceptable. Pneumonia is suggested on a chest x-ray when recent changes are visible and reported by the radiologist or attending doctor. Words used on x-ray reports to denote pneumonia may include Signs of pneumonia Consolidation Shadowing suggestive of pneumonia Findings on the chest x-ray/ct scan should be current and not chronic or historical findings. If there are multiple interpretations of the x-ray/ct scan and any contain abnormal findings that are not documented as chronic or from historic x-ray reports select. If the only findings in the radiology report or consultant (or person working as part of the consultant team) documentation are noted as chronic, historical or normal, select. For example, if the radiology report contains wordings such as changes are similar to those seen on previous x-ray taken on date xx/xx/xxxx". If all findings are chronic Select but if any suggest new findings Select. CT scan report X-ray report PN-01, PN-02, PN-03, PN-04, PN-05 Page 3

4 Q2. Palliative Care PN MDE ID: Palliative_Care_PN2015 ( ) Was the patient commenced palliative care by the post-take ward round? Documentation in the medical record that the patient was commenced on palliative care by the post-take ward round. This includes consultant (or person working as part of the consultant team) documentation of palliative care, within A&E, MAU and post take ward round notes. Any documentation of palliative care after the post take ward round documentation should not be considered. Answers Documentation in the medical record that the patient was commenced on palliative care by the post-take ward round documentation in the medical record that the patient was commenced on palliative care by the post-take ward round. Only accept terms identified in the list of ALLOWABLE VALUES. other terminology will be accepted. If any of the ALLOWABLE VALUES are documented, select '' regardless of other documentation. Consultant (or person working as part of the consultant team) documentation of palliative care (hospice, palliative care, etc.) mentioned in the following contexts suffices: Comfort measures only recommendation; Order for consultation or evaluation by a hospice/palliative care service; Patient or family request for palliative care; Plan for palliative care; Referral to hospice/palliative care service; Advanced care planning; Advanced care plan in place te: Disregard documentation of palliative care (hospice, etc.) written on the day of discharge in any source other than discharge summary OR when it is referring to care planned after discharge only. ALLOWABLE VALUES Comfort measures End of life care Hospice Hospice care Last Days of Life Active Treatment Palliative care Terminal care TLC (Tender Loving Care) VALUES NOT ALLOWED Chemical code only Do not cardiovert Do not defibrillate Do not intubate (DNI) Do t Resuscitate (DNR) Keep comfortable Living will aggressive treatment Page 4

5 antiarrhythmic therapy artificial respirations cardiac monitoring Cardiopulmonary Resuscitation (NCR) CPR chest compressions code Code 99 heroic or aggressive measures intubation and/or ventilation invasive procedures other protocols associated with advanced cardiac life support resuscitative medications resuscitative measures (NRM) vasopressors Supportive care s Nursing records Discharge summary PN-01, PN-02, PN-03, PN-04, PN-05 Page 5

6 Q3. Clinical Trial PN MDE ID: Clinical_Trial_PN2015 ( ) During this hospital stay, was the patient involved in a clinical trial which directly affects the measures in this AQ CFA? Documentation in the medical record that the patient was involved in a clinical trial during this hospital stay, directly affecting AQ Measures (specific to the AQ clinical condition the patient was treated for during this spell of care/treatment). Clinical trials are organised studies to provide large bodies of clinical data for statistically valid evaluation or treatment. These studies are usually rigorously controlled tests of new drugs, invasive medical devices, or therapies on human subjects. Answers Documentation in the medical record that the patient participated in a clinical trial affecting care or treatment related to this AQ measure set documentation in the medical record that the patient participated in a clinical trial affecting care or treatment related to this AQ measure set This data element is used to exclude patients that are involved in a clinical trial during this hospital stay relevant to the measure set for this admission (specific to the AQ clinical condition the patient was treated for during this spell of care/treatment). Consider the patient involved in a clinical trial if documentation indicates: - The patient was newly enrolled in a clinical trial during the hospital stay. - The patient was enrolled in a clinical trial prior to arrival and continued active participation in that clinical trial during this hospital stay. Examples: Hip/Knee, CABG: The patient became involved in a trial of alternate types and routes of prophylactic antibiotics for surgical patients after admission. PN: The patient admitted with pneumonia was previously enrolled in an outpatient clinical trial for pneumonia. After admission to the hospital, the patient continued to take the medication for the trial, as documented on the trial protocol. To answer yes to this data element, there must be formal documentation (trial protocol or patient consent form) in the medical record that the patient was involved in a clinical trial designed to enrol patients with the condition specified in the applicable measure set. If it is not clear which study population that the clinical trial is enrolling, select. Assumptions should not be made if it is not specified. Medical/surgical record Clinical trial protocol Consent forms for clinical trial PN-01, PN-02, PN-03, PN-04, PN-05 Page 6

7 Q4. Transfer from Another A&E Department MDE ID: Transfer_from_Another_A&E_Dept_PN2015 ( ) Was the patient transferred from the A&E department of another hospital? Documentation in the medical record that the patient was transferred from another hospital A&E department. Answers Documentation in the medical record that the patient was transferred from another hospital A&E department documentation in the medical record that the patient was transferred from another hospital A&E department. Accident and emergency department of another hospital includes both A&E department AND observation bed/unit stays at that hospital. If a patient is transferred in from A&E department or observation unit of ANY outside hospital, select, regardless of whether the two hospitals are close in proximity, part of the same hospital system, have a shared medical record or provider number, etc. If a patient is transferred in from a Major Incident Response Team, which provides emergency medical assistance following a catastrophic disaster or other major emergency, select. Ambulance notes Transfer summary PN-01, PN-02, PN-03, PN-04, PN-05 Page 7

8 Q5a. Arrival Date PN MDE ID: Arrival_Date_PN2015 ( ) What is the earliest documented date the patient arrived at the hospital? The earliest documented date (dd/mm/yyyy) that the patient arrived at the hospital for this spell of care/treatment. Answers dd/mm/yyyy UTD Earliest documented date (dd/mm/yyyy) the patient arrived at the hospital for this spell of care/treatment Unable to determine date of arrival from the medical record Electronic Patient Administration System PN-01, PN-02, PN-03, PN-04, PN-05 Page 8

9 Q5b. Arrival Time PN MDE ID: Arrival_Time_PN2015 ( ) What is the earliest documented time the patient arrived at the hospital? The earliest documented time (hh:mm) (24 hour clock) the patient arrived at the hospital. Answers hh:mm UTD Earliest documented time (hh:mm) (24 hour clock) the patient arrived at the hospital for this spell of care/treatment Unable to determine time of arrival from the medical record Electronic Patient Administration System PN-01, PN-02, PN-03, PN-04, PN-05 Page 9

10 Q6. Discharge Time PN MDE ID: Discharge_Time_PN2015 ( ) What is the time the patient was discharged from acute care? The time (hh:mm) (24 hour clock) the patient was discharged from acute care. This is any type of discharge including death or self-discharge. Answers hh:mm UTD The time (hh:mm) the patient was discharged from acute care, left against medical advice, or died during this stay Unable to determine the time the patient was discharged from acute care, left against medical advice, or died during this stay Discharge date is extracted from PbR SuS data, however discharge time is not part of the SuS dataset and must be entered separately. This should be the time recorded in the medical records as the time that the patient was discharged from acute care, left against medical advice, or died. Discharge instruction sheet Discharge summary Proforma Nursing discharge notes Consultant orders Social service notes Transfer record AKI Pathway Electronic Patient Administration System Medical Record Jointly agreed protocol PN-01, PN-02, PN-03, PN-04, PN-05 Page 10

11 Q7. Pneumonia Diagnosis MDE ID: Pneumonia_Diagnosis_PN2015 ( ) Was a final diagnosis/impression of pneumonia documented in the medical record as part of A&E, MAU or post-take ward round documentation, or as an admission diagnosis/impression for a direct admit patient? Documentation in the medical record as part of A&E, MAU or post-take ward round documentation, or as an admission diagnosis/impression for a direct admit patient, that the final diagnosis/impression was of pneumonia. Answers Documentation in the medical record, as part of A&E, MAU or post-take ward round documentation, or as an admission diagnosis/impression for a direct admit patient, that the final diagnosis/impression was of pneumonia. documentation in the medical record, as part of A&E, MAU or post-take ward round documentation, or as an admission diagnosis/impression for a direct admit patient, that the final diagnosis/impression was of pneumonia - Pneumonia diagnosis in A&E department Pneumonia need not be the primary or only diagnosis. For the purpose of this data element, "A&E record" is the document within A&E department which contains the final diagnosis/impression. For patients admitted to observation from A&E department, who later result in inpatient status, a diagnosis/impression of pneumonia must be documented while the patient was in A&E department using the following guidelines. Do not documentation of a differential diagnosis Diagnosis of pneumonia cannot be taken from the chest x-ray, discharge summary or coding documents. Only post take ward rounds taken within 24 hours of the decision to admit may be considered. - Medical Records containing an A&E record completed by A&E department consultant If pneumonia is listed as the final diagnosis/impression on A&E department form by any consultant (or person working as part of the consultant team), select "". further review of additional suggested data sources is needed. If the same A&E department consultant (or person working as part of the consultant team) who completed the A&E record did not include pneumonia as a final diagnosis or impression but completes an admit note or order with an admission diagnosis of pneumonia, select "". - Medical Records do not contain an A&E record completed by A&E department consultant Those cases where the patient is seen in the A&E department but the medical record does not contain an A&E record, which is different than just leaving the form blank (e.g. the consultant treating the patient in A&E department documented everything on an admission note), the admission notes or impression may be written by the admitting consultant (or person working as part of the consultant team) in the first documented progress note. The only data sources that can be used to determine pneumonia diagnosis is the first documentation by the admitting consultant (or person working as part of the consultant team), including the following: A&E notes, medical records and notes documented by the post take ward round. Direct Admit ONLY ACCEPTABLE SOURCES Admitting notes Admitting consultant orders Consultation notes Page 11

12 PN-01, PN-02, PN-03, PN-04, PN-05 Page 12

13 Q8. Diagnostic Uncertainty MDE ID: Diagnostic_uncertainty_PN2015 ( ) Is there documentation of a reason(s) that despite being seen by the consultant (or person working as part of the consultant team), the patient s clinical picture was questionable or unclear and not suggestive of pneumonia? Documentation of a reason(s) that despite being seen by the consultant (or person working as part of the consultant team), the patient s initial clinical picture was questionable or unclear and not suggestive of pneumonia. Answers Documentation in the medical record by a consultant (or part of a consultant team) that the diagnosis of pneumonia was uncertain, questionable, unclear or not suggestive of pneumonia Documentation in the medical record by a consultant (or part of a consultant team) a diagnosis/impression of pneumonia If there is documentation in the medical record by a consultant (or part of a consultant team) that the diagnosis of pneumonia was uncertain, questionable, unclear or not suggestive of pneumonia, select. If there is documentation in the medical record by a consultant (or part of a consultant team) a diagnosis/impression of pneumonia, select. ALLOWABLE VALUES Clinical picture not clear Diagnostic picture unclear t suggestive of pneumonia obvious signs of pneumonia overt evidence of pneumonia Atypical presentation Poor patient cooperation because of impaired mental status PN-03, PN-04, PN-05 Page 13

14 Q9. Chest X-ray - reason MDE ID: Chest_Xray_Reason_PN2015 ( ) Was there a reason documented by the consultant (or part of the consultant team) for not performing a chest x-ray? Documentation in the medical record by the consultant (or part of the consultant team) a reason for not performing a chest x-ray? Answers Documentation in the medical record by the consultant (or part of the consultant team) a reason for not performing a chest x-ray documentation in the medical record by the consultant (or part of the consultant team) a reason for not performing a chest x-ray CT scan report X-ray report PN-02 Page 14

15 Q10a. Chest X-ray Date MDE ID: Chest_X-ray_Date ( ) What was the earliest date a chest x-ray was performed on the patient? The earliest documented date (dd/mm/yyyy) a chest x-ray/ct scan was performed on the patient. Some patients may have a chest x-ray performed prior to arrival at hospital, by their GP or in community care, therefore a negative time of up to 24 hours will pass this measure. Answers dd/mm/yyyy UTD The earliest documented date (dd/mm/yyyy) a chest x-ray was performed on the patient Unable to determine the earliest date a chest x-ray was performed on the patient CT scan report X-ray report PN-02 Page 15

16 Q10a. Chest X-ray Time MDE ID: Chest_X-ray_Time ( ) What was the earliest time a chest x-ray was performed on the patient? The earliest documented time (hh:mm) a chest x-ray/ct scan was performed on the patient. Some patients may have a chest x-ray performed prior to arrival at hospital, by their GP or in community care, therefore a negative time of up to 24 hours will pass this measure. Answers hh:mm UTD The earliest documented time (hh:mm) a chest x-ray was performed on the patient Unable to determine the earliest time a chest x-ray was performed on the patient CT scan report X-ray report PN-02 Page 16

17 Q11. Immunocompromised or Systemic Corticosteroids MDE ID: Immunocompromised_Systemic_Corticosteroids_PN2015 ( ) Was the patient immunocompromised or taking systemic corticosteroids? Documentation in the medical record that the patient had a condition or was taking medication that may result in them being immunocompromised. Answers Documentation in the medical record that the patient was immunocompromised or taking systemic corticosteroids documentation in the medical record that the patient was immunocompromised or taking systemic corticosteroids Patients with conditions which cause problems with immune response include: HIV/AIDS Leukaemia Lymphoma Multiple myeloma Long term steroid therapy Patients on Biological therapies Cancer chemotherapy Immunosuppressive drugs for transplantation Anti-tumour necrosis factor medications for rheumatoid disease Crohn s disease or psoriasis such as infliximab Etanercept or adalimumab Neutropaenia Primary humoral immune deficiency Chronic granulomatous disease Compliment deficiency Myelodysplasia Pancytopaenia GP referral letter Intensive Care Unit notes High dependency unit notes PN-04, PN-05 Page 17

18 Q12. Prior Hospitalisation MDE ID: Prior_Hospitalisation_PN2015 ( ) Was the patient hospitalised in the last 14 days? Documentation that the patient had a prior hospitalisation within 14 days prior to admission. Answers Documentation that the patient had a prior hospitalisation within 14 days prior to admission documentation that the patient had a prior hospitalisation within 14 days prior to admission The intent is to exclude possible nosocomial (hospital acquired) infections, i.e. the patient was discharged from an acute care facility for inpatient care to a non-acute setting (e.g. home, ICF or rehabilitation hospital), before the second admission to the same or different acute care facility. ALLOWABLE VALUES Recent admission date (dd/mm/yyyy, within 14 days of this current admission) Recent stay in an acute care facility for inpatient care date (dd/mm/yyyy, within 14 days of this current admission). VALUES NOT ALLOWED Residential care home stay GP referral letter Discharge summary Intensive Care Unit notes High dependency unit notes PN-04, PN-05 Page 18

19 Q13. Antibiotics - prior MDE ID: Antibiotics_prior_PN2015 ( ) Did the patient receive antibiotic 24 hours prior to arrival at hospital? Documentation in the medical record that the patient received antibiotics 24 hours prior to arrival at hospital. An antibiotic may be defined as any drug, such as penicillin or streptomycin, containing any quantity of any chemical substance produced by a microorganism or made synthetically (i.e. quinolones) which has the capacity to inhibit the growth of or destroy bacteria and other microorganisms. Antibiotics are used in the prevention and treatment of infectious diseases. Answers Documentation in the medical record that antibiotics were administered 24 hours prior to arrival at hospital documentation in the medical record that antibiotics were administered 24 hours prior to arrival at hospital Antibiotics listed as current or home meds, etc. should be inferred as taken within 24 hours prior to arrival, unless there is documentation stating they were not taken within the last 24 hours. If the patient states they took the antibiotic yesterday, even without a time, infer that the antibiotic was taken within 24 hours prior to arrival. When the medical record contains documentation of medication administration such as started on antibiotics two days ago or patient given antibiotics two days ago but the antibiotic is not listed as a current medication and there is no documentation to suggest the medication was taken within 24 hours prior to arrival, this is not enough supporting documentation to indicate that the patient received antibiotics within 24 hours prior to arrival, therefore select. Only consider antibiotics appropriate to this focus area and listed in the Appendix. Do not consider any medications other than antibiotics (i.e., antivirals, antifungals, antituberculins, antiprotozoans, etc.) Only use history dated the day of admission or the day prior to admission. In order to ascertain whether antibiotics were administered during this hospitalisation, please see the detail for the data element, Antibiotic Name. Ambulance documentation Medical/surgical record ICU Flowsheet IV Flowsheet Medication administration record PN-03, PN-05 Page 19

20 Q14. Pulse Oximetry MDE ID: Pulse_Oximetry_PN2015 ( ) Is there documentation a pulse oximetry was performed within 4 hours of hospital arrival? Documentation in the medical record that a pulse oximetry was performed within 4 hours of arrival at hospital. Some patients may have an oxygen assessment performed prior to arrival at hospital, by their GP or in community care, therefore a negative time of up to 4 hours will pass this measure. Pulse oximetry is a noninvasive test to measure the percentage of oxygen saturation of haemoglobin in the patient's arterial circulation. A pulse oximeter may be clipped to a patient's finger to obtain oxygen saturation. Answers Documentation that the pulse oximetry was performed within 4 hours prior to or after arrival at hospital documentation that the pulse oximetry was performed within 4 hours prior to or after arrival at hospital Or unable to determine from the medical record ALLOWABLE VALUES O2 sat Pulse oximetry Pulse ox SaO2 SPO2 VALUES NOT ALLOWED Tests performed after the first 4 hour period are not acceptable Laboratory reports GP/community record PN-01 Page 20

21 Q15. Arterial Blood Gases MDE ID: Arterial_Blood_Gases_PN2015 ( ) Is there documentation an arterial blood gas (ABG) was done within 4 hours of hospital arrival? Documentation in the medical record that arterial blood gases (ABG) were completed within 4 hours of arrival at hospital. Some patients may have arterial blood gases performed prior to arrival at hospital, by their GP or in community care, therefore a negative time of up to 4 hours will pass this measure. ABG is an analysis of the ph, concentration and pressure of oxygen, carbon dioxide, and hydrogen ions in the blood. It is used to assess acid-base balance and ventilatory status in a wide range of conditions. Arterial blood gas (ABG) determination is performed rather than venous blood. Answers Documentation in the medical record that arterial blood gases (ABG) were completed within 4 hours prior to or after arrival at hospital. documentation in the medical record that arterial blood gases (ABG) were completed within 4 hours prior to or after arrival at hospital Or unable to determine from the medical record Laboratory reports GP/community record PN-01 Page 21

22 Q16. CURB-65 Score MDE ID: CURB-65_Score_PN2015 ( ) What is the CURB-65 Score documented on the A&E form, MAU form or first post take ward round record at the hospital? The CURB-65 Score is a method of assessment that grades the severity of pneumonia which aids clinical decisions on how pneumonia patients should be managed. Answers 0 CURB Score = 0: Low severity - likely suitable for home treatment 1 CURB Score = 1: Low severity - likely suitable for home treatment 2 CURB Score = 2: Moderate severity - consider hospital referral 3 CURB Score = 3: High severity - urgent hospital admission 4 CURB Score = 4: High severity - urgent hospital admission 5 CURB Score = 5: High severity - urgent hospital admission 6 documentation by the consultant (or person working as part of the consultant team) of a CURB-65 score on the A&E form, MAU form or first post-take ward round documentation. The CURB-65 score must be documented by a consultant (or other working as part of the consultant team). Select 6 (ne) If there is no numeric value documented (0-5) for the CURB-65 score If the CURB-65 score is not documented on the A&E form, MAU form or the first post take ward round record, 6 (ne) must be selected selection If the CURB-65 score is documented as a range (2-3, 4-5, etc), select the lowest numeric value If there is more than one CURB-65 score documented on the A&E form, MAU form or the first post take ward round record, select the one with the latest documented date and time EXCLUSION CURB-65 score documented anywhere except the A&E form, the MAU form or the first post take ward round record. CURB-65 score described only with individual narrative description but does not have a numeric calculation/value. MAU documentation First post take ward round record PN-04 Page 22

23 Q17. CC by Post Take Ward Round MDE ID: CC_by_Posttake ( ) Was the patient admitted to Critical Care/ICU by the post-take ward round? The patient was admitted to Critical Care/ICU by the post-take ward round and was assessed using a severity scoring tool. Answers The patient was admitted to critical care/icu by post-take ward round The patient was not admitted to critical care/icu by the post-take ward round Patients that are admitted to the critical care environment are often assessed using a severity score as an alternative to the CURB-65 score. Patients can be excluded from the CURB-65 measure if they are admitted to critical care by the post-take ward round. Intensive Care Unit notes PN-04 Page 23

24 Q18. Pneumonia Pathogen Identified MDE ID: Pneumonia_Pathogen_Identified_PN2015 ( ) Is there documentation that the patient had a positive diagnostic test for pneumonia pathogen on arrival or within 24 hours of arrival at hospital? Documentation that the patient had a positive diagnostic test for a pneumonia pathogen on arrival or within 24 hours of arrival at hospital. A positive diagnostic test for pneumonia pathogen is defined as any of Known positive blood or sputum culture Positive urinary antigen test for streptococcus pneumoniae or legionella pneumophilia Positive Polymerase Chain Reaction (PCR) test for legionella pneumophilia Answers Documentation that the patient had a positive diagnostic test for a pneumonia pathogen on arrival or within 24 hours of arrival at hospital documentation that the patient had a positive diagnostic test for a pneumonia pathogen on arrival or within 24 hours of arrival at hospital Test results must be available/reported within 24 hours after arrival to the hospital. The 24 hours after arrival is the same for patients who arrive through A&E department or as a direct admit. PN-05 Page 24

25 Q19. Another Suspected Source of Infection MDE ID: Another_Suspected_Source_of_Infection_PN2015 ( ) Was there another suspected source of infection in addition to pneumonia? Documentation in the medical record that there was another suspected infection, in addition to pneumonia, within 24 hours of arrival at hospital Answers Documentation in the medical record that there was another suspected infection, in addition to pneumonia, within 24 hours of arrival at hospital documentation in the medical record that there was another suspected infection, in addition to pneumonia, within 24 hours of arrival at hospital Or unable to determine from the medical record Documentation of the infection/suspected infection, other than pneumonia, must be within 24 hours of arrival at hospital in order to select. Only consider infections/suspected infections that are being/will be treated by an antibiotic listed in Appendix V, Table 2.1, that are administered via routes PO, IM or IV. There does not need to be documentation that ties the antibiotic to the infection/suspected infection, as one antibiotic may cover multiple infections. Documentation of signs or symptoms (e.g., fever, elevated white blood cells, etc) should not be considered infections unless documented as an infection or possible/suspected infection. For example, do not assume infection if a wound/surgical site is described as reddened, swollen and hot, as other conditions can also cause these symptoms. This data element will accept both suspected infections and diagnosed infections, for example Upon arrival, there is Consultant documentation the patient has cellulites, select In A&E Department, after arrival, there is consultant documentation that she suspects the patient has a UTI, select ALLOWABLE VALUES Abscess outside of the lung Cellulitis Infected skin ulcer Intra-abdominal infections (e.g., cholecystitis, diverticulitis, cystitis, pyelonephritis) Meningitis Osteomyelitis or septic joint (infective arthritis) Prostatitis Urinary Tract infection VALUES NOT ALLOWED Any infection in the respiratory tract (sinusitis, laryngitis, bronchitis, pleurisy, other lung infections) Bacteremia or blood stream infections (unless there is another infection outside of the respiratory PN-05 Page 25

26 Q20a. Antibiotic - name MDE ID: Antibiotic_name_PN2015 ( ) What is the name of the antibiotic administered during hospital stay? Documentation in the medical record of the name of the antibiotic administered during hospital stay. An antibiotic may be defined as any drug, such as penicillin or streptomycin, containing any quantity of any chemical substance produced by a microorganism or made synthetically (i.e. quinolones) which has the capacity to inhibit the growth of or destroy bacteria and other microorganisms. Antibiotics are used in the prevention and treatment of infectious diseases. Answers Antibiotic Grid is populated with an antibiotic name Antibiotic Grid is not populated Collect only antibiotics administered via an appropriate route to answer this question. The use of hang time or infusion time is acceptable as antibiotic administration time when other documentation cannot be found. If an antibiotic is started and the infusion is interrupted by an event such as the IV being dislodged, the tubing becoming disconnected, or the patient experiencing an allergic reaction, abstract the time the infusion was started. Similarly, if a patient vomits after an oral antibiotic is administered, abstract the time the antibiotic was administered. Only use Antibiotic NOS in the following situations: -For new antibiotics that are not yet listed in Table 2.1 -When there is documentation an antibiotic was administered but unable to identify the name. It must be apparent that the medication is an antibiotic. Example: On , contains the documentation Antibiotic started name illegible, 2gm, IV, 02:00-HF. In the antibiotic grid, Antibiotic NOS would be entered for the name, IV for the route, 02:00 for the time and for the date. (If Antibiotic started had not been documented in this example, the medication could not be abstracted as an Antibiotic Received). A specific antibiotic is defined as having a single generic name and being administered via a single appropriate route (if trade names are used, a reference table is provided in Appendix V of the PN2015 Measure Document, Table 2.1). If the route of administration of an antibiotic changes during the hospital stay (from arrival to 36 hours for PN) record the antibiotic name once for each route by which it was administered. Example: A patient arrives at the hospital at 07:15 on Zithromax IV is administered in A&E department at 09:30 on On at 09:00, Zithromax PO is recorded as administered on the medication administration record. Enter: Zithromax , 09:30, IV and Zithromax , 09:00, PO. Do not abstract antibiotic administration information for a specific antibiotic from more than one data source. For EACH antibiotic name, enter an Antibiotic Administration Route, Date, Time. If all information (antibiotic route, date and time) is not contained in a single data source for that specific antibiotic, utilise UTD for the missing information. Either a signature or initials signifying administration of the medication is required to abstract a specific antibiotic. Document the name of each antibiotic administered PO, IV, and IM during the first 36 hours after hospital arrival. If an antibiotic is administered more than once by the same route during the first 36 hours after hospital arrival, only record the antibiotic name once. Page 26

27 Intensive care unit record IV flowsheet Medication administration record PN-03 Page 27

28 Q20b. Antibiotic Date MDE ID: Antibiotic_date_PN2015 ( ) What was the date of administration for the antibiotics? The earliest documented date (dd/mm/yyyy) on which the antibiotic was administered. Answers dd/mm/yyyy UTD The earliest documented date (dd/mm/yyyy) antibiotics were administered Unable to determine from the medical record Medical/surgical record Intensive care unit record IV flowsheet Medication administration record Anaesthesia record Operation notes PN-03 Page 28

29 Q20c. Antibiotic Time MDE ID: Antibiotic_time_PN2015 ( ) What was the earliest time of administration for the antibiotic dose? The earliest documented time (hh:mm) (24 hour clock) at which the antibiotic was administered. Answers hh:mm UTD Earliest documented time (hh:mm) antibiotics were administered Unable to determine from the medical record Medical/surgical record Intensive care unit record IV flowsheet Medication administration record Anaesthesia record Operation notes PN-03 Page 29

30 Q20d. Antibiotic - route MDE ID: Antibiotic_Route_PN2015 ( ) What was the antibiotic administration route? The route via which the antibiotic was administered Answers 1 1: Oral 2 2: Intravenous 3 3: Intramuscular 4 4: Rectal N Z N: t Applicable Z: Unknown Include any antibiotics given: Intravenous: - Bolus - Infusion - IV/I.V. - IV piggyback/ivpb - Parenteral - Perfusion PO/NG/PEG tube: - Any kind of feeding tube (e.g. percutaneous endoscopic gastrostomy, percutaneous endoscopic jejunostomy, gastrostomy tube) - By mouth - Gastric tube - G-tube - Jejunostomy - J-tube - Nasogastric tube - PO/P.O. Refer to Appendix V of the Pneumonia 2015 Measure Document for a comprehensive list of medications. NON APPLICABLE TERMINOLOGY - Abdominal irrigation - Chest irrigation - Eardrops - Enema/rectally - Eyedrops - Inhalation - Intracoronary - Joint irrigation - Mixed in cement - Mouthwash - Nasal sprays - Peritoneal dialysate (antibiotic added to) Page 30

31 - Peritoneal irrigation - Swish and spit - Swish and swallow (S/S) - Topical antibiotics - Troches - Vaginal administration - Wound irrigation Collect only antibiotics administered via an appropriate route to answer this question: PNEUMONIA: PO, IV and IM Intensive care unit record IV flowsheet Medication administration record PN-03 Page 31

32 Q21. Antibiotic - appropriate regime MDE ID: Antibiotic_appropriate_regime_PN2015 ( ) Did the patient receive the appropriate antibiotic regime? Evidence that the antibiotics the patient received were administered appropriately as per the local hospital protocol. Answers Evidence that the antibiotics the patient received were administered appropriately as per the local hospital protocol evidence that the antibiotics the patient received were administered appropriately as per the local hospital protocol. Appropriate antibiotic regime is defined as a regime that follows local hospital policy. Consider the current local guidelines carefully making sure the appropriate drug(s) as well as the appropriate route of administration is used. See Appendix V of the PN2015 Measure Document - Table 2.1 for the list of allowable antibiotics Appropriate administration routes for this measure PNEUMONIA: PO, IV and IM If the route of administration of an antibiotic changes during the hospital stay (within 36 hours of arrival of arrival for PN ) record the antibiotic name once for each route by which it was administered. Antibiotic administration route should reflect the CURB-65 score and be consistent with current local guidelines unless otherwise specified by the consultant team. If there is a change to the antibiotic regime outlined in the policy due to a clinical decision i.e. that patient shows severity greater than the CURB-65 score, as long as this is clearly documented in the medical record, select '', Example: the patient's CURB-65 = 0 and is given IV antibiotics, the local policy is for 0-1 CURB-65 to have oral antibiotics therefore the patient will fail unless specified in the medical records by consultant (or member of consultant team) to 'treat as severe'. Other examples may include Patient CURB-65 = 0, given IV antibiotics due to severity Patient CURB-65 = 1, however requires 2 antibiotics due to severity of illness Medical/surgical record Medication administration record Intensive care unit notes High dependency unit notes PN-05 Page 32