Background The Pediatric Private Duty Nursing Qualification Assessment tool is designed to accurately determine a client s need for private duty nursing hours, while considering all conditions which require the intervention of a skilled nurse. The assessment should be completed by a nurse with extensive pediatric experience. Using this tool does not preclude the need to complete a full assessment of the client s health and environment using an instrument such as OASIS. This tool is intended for pediatric patients (0 18 years) who live at home, presuming capable parental/responsible party involvement. Section 1 Complete the form for any of the following events (check all that apply): New discharge from hospital Change from one PDN agency to another Annual assessment Significant change in client condition (improvement or decline examples: vent, IV, med regimen) New diagnosis Recertification/Other Assessment performed by (print) Date Signature and Licensure Client information Name DOB Address Phone Responsible party Insurance carrier and ID Primary diagnosis/onset date Secondary diagnosis/onset date Secondary diagnosis/onset date History Section 2 Exemption criteria: Trach and 24/7 ventilation, new discharge to home. Does client meet these criteria? Yes Client qualifies for 24/7 PDN for 2 months. Use qualification tool again at the end of this period to re assess authorization. No Complete Sections 3 and 4 Approved 12 01 2010 Page 1 of 6
Section 3 a. Select the primary diagnosis which requires skilled nursing interventions: Respiratory Ventilator Use, Respiratory Other, Cardio, Neurology, Vascular/IV b. Using the table below, select the row for the primary diagnosis chosen in (a). Then choose the column which best describes the client. Condition 120 100 80 Definitions Respiratory Vent dependent 24 Vent dependent 23 Vent dependent less Ventilation is defined as CPAP, Bi level, and ventilator application to Vent hours/day 12 hours/day than 11 hours/day tracheostomy. Non invasive (nasal or mask) CPAP or Bi level is considered ventilation if it is life sustaining for conditions such as central hypoventilation syndrome, SMA, MD, and spina bifida. Exclusions include CPAP and Bi level to mouth for obstructive sleep apnea and other conditions that are not life threatening. Condition 60 40 20 Skilled visits Definitions Respiratory Stable trach and medically stable Other Respiratory assessment and monitoring for aspiration, resp distress, choking, recurring infection Stable trach with medically unstable conditions Respiratory assessment and monitoring for recurring resp infection Recurring hospitalizations for asthma exacerbation Updated 12 21 2010 Page 2 of 6
Condition 40 Skilled visits Definitions Cardiac Unstable cardiac condition Life threatening episodes Stable condition Monitoring of medications and med documented within the last 180 days. administration Condition 40 20 Definitions Neurology Daily seizures requiring skilled intervention and Other Neuro spasms, complex meds Requires skilled assessment and intervention. complex medications determined via assessment Includes medication intervention. Seizures that are controlled or that only require observation do not score points. Condition 120 60 Skilled visits Definitions Vascular/IV Continuous TPN or life sustaining Daily TPN or life sustaining meds Weekly or bi weekly TPN, lipids, meds antibiotics or other meds. List the highest hourly qualification for this table. Transfer this number into section 4. Updated 12 21 2010 Page 3 of 6
Section 4 Circle all conditions that apply to patient a. Client age is 5 months or less 10 b. Client weighs less than 5kg 10 c. 3 or more systems are diseased/have 10 diagnosis d. 2 or more systems are diseased/have diagnosis 5 e. First time discharge from hospital or new diagnosis within 1 month. f. Client has been hospitalized for this condition in the past 90 days g. Client would not survive decannulation or Client has unstable airway with no trach and airway would collapse without proper positioning and intervention (example SMA, MD) h. Client needs suction at least once per hour Choose from these systems for conditions that require skilled intervention. If condition is stable and does not require intervention, it does not qualify for points.: Respiratory/Airway Neurological Cardiac Gastrointestinal Vascular (Infusion) Muscular/Skeletal Genito/Urinary 20 If you use this category, do not assign points for unplanned hospitalizations **Must re assess after one month. These additional points are intended for family education purposes. 5 Unplanned admission due to acute medical episode related to primary diagnosis in section 3. 10 Decannulation survival generally depends on a tracheal condition where the trachea would collapse without the trach tube in place such as tracheal malacia. 5 Non trached clients with unstable airway generally have a neuro/muscular primary condition that would cause airway to collapse without proper positioning and intervention such as SMA or MD. Updated 12 21 2010 Page 4 of 6
i. Client has complex medication/respiratory therapy regimen. Client must have had an adverse reaction in the last 120 days to qualify. 10 Complex: High risk of adverse reaction or requires skilled assessment to perform/change med regimen. Examples: O2 dependence, allergic reaction, high blood pressure, seizure, diuretic, narcotics. Non complex Low risk of adverse reaction or need to change med regimen. j. Client has complex feeding regimen 10 Complex: risk of aspiration, oral therapies, gag/intolerance/retching, reflux, vented GT, transition phases such as increasing amounts, orders to perform as tolerated. ***Continuous feedings at a standard rate are not complex. k. Complex social, family, environmental issues l. High acuity/morbidity risk and lives more than 40 miles from a medical facility that can meet the client s acuity of care Total for section 4 5 Examples: language barriers, physical limitations, single parent home, other children under 5 yrs old, both parents work FT+, first time discharge/new diagnosis, first time parents, other issues and road blocks 5 Score from section 3 plus score from section 4 = Total Section 5 Scoring Points Client qualifies for PDN 168 140 24 20 hours per day 139 112 20 16 hours per day 111 84 16 12 hours per day 83 56 12 8 hours per day 55 26 8 4 hours per day of PDN or Skilled nursing visits 25 and under No PDN, assess for skilled nursing visits and PCA Updated 12 21 2010 Page 5 of 6
Primary Physician Consulting Physician(s) PDN Hours ordered by physician Other significant information related to client cares/nursing hours. Updated 12 21 2010 Page 6 of 6