1. © 2004-2007 Grey Bruce Health Network Community-Acquired Pneumonia Education Workshop (click to go to the desired section) Introduction to Workshop/Instructions Evidence-Based Care Program Community-Acquired Pneumonia Workshop

2. © 2004-2007Grey Bruce Health Network Introduction This interactive workshop is designed to go along with a copy of the pathway. Keep the pathway handy as you go through the workshop to engage in the required activities. This is a web-based workshop, and has links throughout each page to enable you to move throughout the workshop. Whenever you see words underlined like this, you can click on that area to go to another section or to find more information on a topic.underlined like this At the bottom of each page are navigational buttons to help you move through the workshop. You can go through as much or as little of the workshop as you like at a time. If you have any questions about how to use this workshop or the individual pathways, feel free to ask your Site Champion or contact the Evidence-Based Care Program. Back to Start of Workshop NextBack

3. © 2004-2007Grey Bruce Health Network These pathways have been developed as a part of the Evidence-Based Care Program, which is Schedule 6 in the agreement of the Grey Bruce Health Network. The intent is to develop regional pathways and other evidence-based tools that flow across all hospitals and community services in Grey and Bruce (including Grey Bruce Health Services, Hanover and District Hospital, South Bruce Grey Health Centre, the Community Care Access Centre, and Grey Bruce Health Unit). It is hoped that these pathways will improve: Coordination of care through more communication across professions; Continuity of care, through increased linkages among hospitals and the CCAC; Clinical outcomes, through increased usage of best practices; and Patient satisfaction, through linked expectations and increased patient teaching at our agencies. Back to Start of Workshop NextBack

4. © 2004-2007Grey Bruce Health Network Community-Acquired Pneumonia Pathway The Community-Acquired Pneumonia (CAP) pathway consists of 6 parts: Clinical Practice Guideline Pre-Printed Orders Clinical Pathway Patient Pathway Patient Education Booklets Teaching Checklist Back to Start of Workshop NextBack

5. © 2004-2007Grey Bruce Health Network CAP – Clinical Practice Guideline The Clinical Practice Guideline for CAP is a reference document only, and is found with the CAP pathway materials on the GBHN website at www.gbhn.ca under Current Initiativeswww.gbhn.ca It summarizes all of the evidence used in the development of the pathway. It can be referred to when a provider has questions about the content of the pathway. Back to Start of Workshop Back to beginning of CAP section NextBack

6. © 2004-2007Grey Bruce Health Network CAP – Pre-Printed Orders Community-Acquired Pneumonia orders  Used for patients with a primary diagnosis of Community –Acquired Pneumonia who do not have any exclusion criteria Back to Start of Workshop Back to beginning of CAP section NextBack

7. © 2004-2007Grey Bruce Health Network Inclusion Criteria Inclusion Criteria: Patients with Community-Acquired Pneumonia Exclusion Criteria: Patients Less than 16 years old Immunocompromised patients Hospital Acquired Pneumonia (onset after 4 days of hospitalization) Aspiration Pneumonia Patients with cystic fibrosis or tuberculosis Pregnant women Back to Start of Workshop Back to beginning of CAP section NextBack

8. © 2004-2007Grey Bruce Health Network CAP Pre-Printed Orders The Community Acquired Pneumonia orders have two regimens of antibiotics to choose from. The physician can choose which regimen is most appropriate for each patient. Residents of LTC facilities are often frail and elderly and require very individualized care. However, evidence shows that often, these patients are most appropriately prescribed Regimen 2 on the Community Acquired Pneumonia orders. It is up to the physician to determine appropriate antibiotics for these patients. On the back of the order set, is a prediction model for identifying patients who require hospitalization and who can be treated as an outpatient. The physician may refer to this model to help determine if the patient needs to be admitted. It scores patients based on their characteristics and assigns them a risk class, which then provides recommendations for their care. The orders are a guideline only, and a physician can change any order for patient individualization. Back to Start of Workshop Back to beginning of CAP section NextBack

9. © 2004-2007Grey Bruce Health Network Clinical Pathway The Community-Acquired Pneumonia pathway is a Phase-type pathway with two phases.Community-Acquired Pneumonia pathway The pathway is put on the chart when the patient is determined to require admission for Community Acquired Pneumonia. Phase 1 is approximately 2 days. The patient should remain in this phase, receiving this care, until the patient outcomes at the top of the page have been achieved. If the outcomes have been achieved before the 48 hours, flip the pathway to the next page and begin Phase 2. If 48 hours have passed and some outcomes have not been met, the patient will need to stay in Phase 1 until the outcomes have been met. Thus, you will need to get an additional blank page of Phase 1, put it in the chart, and keep using Phase 1 until the outcomes have been met. Back to Start of Workshop Back to beginning of CAP section NextBack

10. © 2004-2007Grey Bruce Health Network Phase 1 Patient Outcomes Normal mental status( or usual mental status) Respiratory rate 30/min or less for 24 hrs Systolic BP >90 for 24 hrs Temperature 36-38.5 for 24hrs Heart rate <120 BPM for 24hrs Decreased dyspnea,cough and sputum production Back to Start of Workshop Back to beginning of CAP section NextBack

11. © 2004-2007Grey Bruce Health Network Clinical Pathway The same goes for Phase 2, except there are 72 hours to achieve the outcomes. Once the patient achieves the outcomes, move to the Discharge Criteria. The Discharge Criteria should be checked daily to see if the criteria have been met. Once all the criteria have been met, then the patient should be ready for discharge. We are currently not tracking any indicators in this pathway Back to Start of Workshop Back to beginning of CAP section NextBack

12. © 2004-2007Grey Bruce Health Network Phase 2 Patient Outcomes Off supplemental oxygen or on usual O 2 Temperature < 38 for 24hrs or greater Understands diagnosis and discharge plan Back to Start of Workshop Back to beginning of CAP section NextBack

13. © 2004-2007Grey Bruce Health Network CAP Patient Pathway The patient pathway has four sections to it:patient pathway Admission – describes what will happen to the patient at admission. Phase 1 – describes what is done during the first two days of hospitalization, or until the patient achieves the patient outcome indicators for this phase. Phase 2 – describes what is done during the next three days of hospitalization, or until the patient achieves the patient outcome indicators for this phase. Discharge Criteria – describes what the goals are for discharge. This should be given to the patient early in his/her hospital stay and referred to each day to help the patient understand what is happening to him/her. Back to Start of Workshop Back to beginning of CAP section NextBack

14. © 2004-2007Grey Bruce Health Network Patient Education There are two education booklets for this pathway: Outpatient booklet – is given to any patient who is not admitted for pneumonia but will be treated as an outpatient. Outpatient booklet Inpatient booklet – is given to all patients on the pathway, and referred to throughout the patient’s stay to help him/her understand his/her condition. Inpatient booklet Teaching Checklist This is a list of the topics that should be taught or reviewed with the patient before discharge. (see sample)(see sample) Place the checklist on the chart, and indicate on it as topics are covered so others know what has been taught. Back to Start of Workshop Back to beginning of CAP section NextBack

15. © 2004-2007Grey Bruce Health Network End of CAP Section This is the end of the general information for the CAP pathway. To get further information by trying the pathway on a sample patient, move to the Simulation portion of the CAP workshop.Simulation Test your knowledge of CAP by doing the CAP quiz.CAP quiz. Back to Start of Workshop Back to beginning of CAP section NextBack

16. © 2004-2007Grey Bruce Health Network Simulation Try it! Take a look at the pathway.Take a look at the pathway. Jane arrives in hospital with pneumonia symptoms. She is diagnosed with probable pneumonia and the attending physician decides to admit her. You check the pathway and Jane fulfills the inclusion criteria for the pathway – find the inclusion and exclusion criteria on the first page of the pathway. The pathway should be started in Emergency, as this is where the care begins. If the patient is directly admitted from the physician’s office, the pathway can be started on the unit. The clinical pathway and teaching checklist goes on the chart, and the patient pathway and patient education materials are given to Jane.teaching checklist Back to Start of Workshop Back to beginning of CAP section NextBack

17. © 2004-2007Grey Bruce Health Network Phase 1 Flip the page to Phase 1: On the first page of each pathway will be a section for comorbid conditions. Please list any conditions the patient has other than pneumonia, that may affect the care you are giving. This will help health records in coding this patient appropriately. You will then see two columns on the right hand side – each has “Date” at the top. Write in today’s date at the top of the first column. Under that, there are three columns, each corresponding to a shift for that 24 hour period. In the first column, write in the hours you will be caring for Jane. You will then use this column to initial as each task on that page is completed. (see a sample page completed). Use your corporate progress notes if you require further documentation.(see a sample page completed). The first sections, on the left, are the Patient Outcomes. Monitor these indicators, and initial/date them as they are met. Back to Start of Workshop Back to beginning of CAP section NextBack

18. © 2004-2007Grey Bruce Health Network Completing Documentation Phase 1 The rest of the page, and going on to the back of the page, lists the tasks that should be completed during this phase. For example, under assessments, Vitals should be taken Q4H &PRN, including O 2 Sats. Initial in the column to the right that corresponds to your shift as each task is completed. This is repeated for each shift and each profession charting in the section they have completed, until the Patient Outcomes have been achieved. Some tasks are not appropriate for all patients or all time frames. In these cases, you can indicate N/A and initial to show this. For example, if Jane does not have a productive cough, then in the Diagnostics/ Laboratory section under “Sputum for C&S & Gram Stain When Productive”, you would indicate “N/A” and initial. Also, if it is night shift, you will most likely not be teaching the patient, so under Psychosocial Support/Education”, you can indicate “N/A” and initial “Review Patient Pathway” and “Start Teaching Checklist”. (see a sample page completed)(see a sample page completed) Back to Start of Workshop Back to beginning of CAP section NextBack

19. © 2004-2007Grey Bruce Health Network Phase 1 Patient Outcomes The patient outcome need to be assessed daily to see if they have been met. At the end of your shift, look at the patient outcomes. Have any outcomes been met? In Jane’s case, let’s say she has normal mental status – initial and date this indicator. However, the others have not yet been achieved, so they are left blank for the time being, until they are achieved. Jane needs to remain in Phase 1 until these outcomes have been met. If all the patient outcomes had been met, initial and date them, and move to Phase 2 (even if it has been less than the 2days or 48hrs). Back to Start of Workshop Back to beginning of CAP section NextBack

20. © 2004-2007Grey Bruce Health Network Teaching Checklist On each day of all pathways, you will notice a referral to a Teaching Checklist and a Patient Pathway. The Teaching Checklist should be on the chart and be filled in as topics are covered with Jane. This way the next nurse on shift will know what has been covered and can continue down the list. The Patient Education Materials can be referenced to aid you in teaching. Also, the Patient Pathway should be referred to on a daily basis to help Jane understand the plan of care. Back to Start of Workshop Back to beginning of CAP section NextBack

21. © 2004-2007Grey Bruce Health Network Discharge Planning At the end of each day, in the Discharge Planning section (last section of each page), you will notice it says “Assess Discharge Criteria Daily”. This means you will need to flip to the Discharge Criteria on a daily basis, at some point during the day, and check if any of these goals have been met. If they have, initial and date them. Once all of these criteria have been met, Jane is ready to go home. Back to Start of Workshop Back to beginning of CAP section NextBack

22. © 2004-2007Grey Bruce Health Network Phase 2 Let’s assume Jane continues to have a cough, but all other outcomes have been met. Jane needs to remain in Phase 1 until this has been met (or, if you know from history and experience that this outcome will never be met, due to a complication in Jane’s condition, you can move her to Phase 2, it is your judgment call). But you have run out of room on the page to chart the following day. On your unit, there will be extra Phase 1 pages or they can be printed from wwwgbhn.ca. Slip this extra Phase 1 page in the pathway and continue using it until that last outcome has been met. The same is repeated for Phase 2, except that the deadline for the patient outcomes to be met on this phase is 3 days, or 72 hours. Back to Start of Workshop Back to beginning of CAP section NextBack

23. © 2004-2007Grey Bruce Health Network Simulation Discharge or Transfer Let’s assume it is 48 hours into Phase 2, and Jane has now achieved all the patient outcome indicators. As soon as these criteria have been met, she can go home. If Jane is transferred to another hospital, there are instructions for this on the first page of the pathway (the same page that you looked at for the indications for inclusion or exclusion). Make sure the proper materials get forwarded to the receiving hospital, so they can continue using the pathway. Back to Start of Workshop Back to beginning of CAP section NextBack

24. © 2004-2007Grey Bruce Health Network CAP Quiz 1. What are the inclusion/exclusion criteria for the CAP pathway? 2. This pathway has two phases. How do patients move from one phase to another? 3. What do you do with the patient pathway and patient education materials? 4. What do you do with the teaching checklist? 5. What do you do if a patient remains in a phase longer than the 48 or 72 hours approximated on the pathway page? Back to Start of Workshop Answers Back

25. © 2004-2007Grey Bruce Health Network CAP Quiz Answers 1. What are the inclusion/exclusion criteria for the CAP pathway? All patients who have Community Acquired Pneumonia can be put on this pathway, unless they are less than 16 years old, immunocompromised, have hospital acquired pneumonia, aspiration pneumonia, cystic fibrosis, tuberculosis, or are pregnant. 2. This pathway has two phases. How do patients move from one phase to another? When a patient meets the patient outcome indicators, he/she can move from one phase to the next. 3. What do you do with the patient pathway and patient education materials? These are given to the patient at admission and used for patient teaching and to help the patient understand what is happening during hospitalization. Back to Start of Workshop Back

26. © 2004-2007Grey Bruce Health Network CAP Quiz Answers 4. What do you do with the teaching checklist? This should go on the chart and be filled in as topics are covered. The teaching checklist should be finished by the time the patient is discharged. 5. What do you do if a patient remains in a phase longer than the 48 or 72 hours approximated on the pathway page? The patient needs to stay in this phase until all the patient outcome indicators have been met, so additional pages (blank) for this phase can be inserted into the pathway and used until the indicators have been met unless the outcome is determined to be unachievable (all corrective actions exhausted) then you would proceed to the next phase. If you have had difficulty with any of these questions, go back through the material on this pathway and/or the general pathway information in this workshop, or ask your Site Champion or contact the Evidence-Based Care Program for any other questions you have. Back to Start of Workshop Back