TE/POST

APAC
ACUTE CARE
CENTRAL COAST Telephone: (02) 4320 3482 Facsimile: (02) 4320 3555

Professional Health Care in Your Own Environment

NORTHERN SYDNEY Telephone: (02) 9926 7292 Facsimile: (02) 9926 5997

APAC CLINICAL GUIDELINES FOR THE MANAGEMENT COMMUNITY ACQUIRED PNEUMONIA

ACUTE/POST ACUTE CARE (APAC) NORTHERN SYDNEY CENTRAL COAST HEALTH

Authors: Jane Whitehurst, Clinical Nurse Consultant - NSCCH

S:\Clinical & Operational Policies & Procedures/APAC Protocols/Pneumonia 7/06/2007

This page is blank.

S:\Clinical & Operational Policies & Procedures/APAC Protocols/Pneumonia 7/06/2007 2

COMMUNITY ACQUIRED PNEUMONIA APAC NSCCH CLINICAL GUIDELINES

APAC Contact Numbers
NORTHERN SYDNEY Hospital In-patients: Monday to Friday 8.00am 5.00pm (02) 9926 7292 Monday to Friday 5.00pm 11.00pm. Weekends and Public Holidays (02) 9926 7111 ask for APAC Nurse to be Paged APAC/GP Shared Care Program Patients: 7 days a week, including Weekends and Public Holidays 0421 582 997 7.00am 11.00pm CENTRAL COAST 7 days a week, including Weekends and Public Holidays Pone: (02) 4320 3482 7.00am 11.00pm Fax: (02) 4320 3555

Referrals Taken: 7.00am 11.00pm Daily

Clinical Guideline Statement

APAC provides comprehensive and evidence based treatment through a coordinated multidisciplinary team, who operate according to agreed clinical pathways. This model of care is supported by data from the Therapeutic Guidelines (Respiratory 2005 & Antibiotic 2006) and The CAPTION Project where APAC is documented as Hospital in the Home for management of Community Acquired Pneumonia (CAP) and Institute for Clinical Systems Improvement Health Care Guideline (2005). (See appendices for APAC clinical pathways). APAC aims to provide patient education, treatment, assessment and support, in order to improve disease management, quality of life, and prevent recurrent disease thereby decreasing hospital admissions. The patient must give verbal/written consent to home therapy, meet all the APAC criteria and be able to be safely managed at home.

Background
Community acquired pneumonia is defined as a pneumonia occurring in individuals who are not in hospital or have been hospitalised for less than 48 hours, and are not significantly immunocompromised. (Therapeutic Guidelines: Respiratory 2005) CAP can be caused by bacteria, fungi, viruses, and parasites, the predominant causative organism is Streptococcus pneumoniae, followed by, Haemophilus influenzae, Staphylococcus aureus, Mycoplasma pneumoniae, and occasionally Chlamydophila pneumoniae, Moraxella catarrhalis, and Legionella species. The relative frequency of these pathogens differs with the age of the patient and the severity of the pneumonia. The organism causing pneumonia may be identified from cultures of blood, sputum, pleural fluid, pulmonary tissue, or endobronchial secretions. (File et al, 2004)
S:\Clinical & Operational Policies & Procedures/APAC Protocols/Pneumonia 7/06/2007

Scope of Practice
First Dose of Intravenous Antibiotic should be administered either within a Hospital facility or by/in the presence of the General Practitioner. Accredited Registered Nurses patient assessment and monitoring and education. Administration of 2nd and consecutive doses of IV antibiotics. Medical practitioners patient diagnosis, clinical management plan and review. Physiotherapist patient assessment and physiotherapy. Occupational Therapist patient and environment assessment and education. Pharmacists medication review and patient education. Social Worker - liaise, assess and provide the patient with appropriate assistance and support.

Expected Outcomes

Clinical improvement and improvement of symptoms. Improved health status and function. Identification and management of risk factors. Referral to community support services if required. Readmission to Hospital if no improvement/deterioration The patients CAP will resolve through treatment at the patients home setting delivered by the APAC NSCCH service (Therapeutic Guidelines: Antibiotics, 2006). The patient will be admitted through either the in-patient, Emergency Department, VMO (Visiting Medical Officer)/SMS (Senior Medical Officer) or directly via the GP (General Practitioner) route. The treatment plan will be by the use of various intravenous antibiotics set out further on in this clinical guideline. (Howden & Grayson, 2002)

Definitions
CAP Community Acquired Pneumonia COPD Chronic Obstructive Pulmonary Disease Community Acquired Infection An infection contracted outside of a health care setting, often distinguished from nosocomial, or hospital-acquired, diseases by the types of organisms (Mosby, 2006). Creatinine Clearance a diagnostic test for kidney/renal function (Mosby, 2006). GP General Practitioner ID Infectious Diseases SMS Senior Medical Officer/Consultant VMO Visiting Medical Officer/Consultant NSCCH Northern Sydney Central Coast Health Hospital Facility In-patient A patient who has been admitted to APAC through the hospital facility either from the Wards, Emergency or EMU departments. Mode of Referral Refers to the form of medical health professional who is referring a patient, e.g. SMS/VMO, GP, Nursing or Allied Health Worker. Clinical Management Refers to the medical responsibility and management of a patient, this will be either the SMS or GP. APAC /GP Shared Care Program (GP Direct Referrals) - The APAC/GP Shared Care program is an extension of the APAC service that enables GPs to directly refer and access the APAC service. It enables GPs to determine and initiate the clinical management of their patient before referring the patient to APAC for them to perform the clinical treatment. The APAC program aims avoids unnecessary hospital presentations.
S:\Clinical & Operational Policies & Procedures/APAC Protocols/Pneumonia 7/06/2007 4

Referral to APAC NSCCH

APAC NSCCH has two main modes of referral designations, either Hospital Facility Inpatient/VMO or GP designations. 1. APAC NSCCH Admission Criteria To be admitted to APAC NSCCH the patient should fulfil the APAC Assessment Criteria
(Howden & Grayson, 2002):

Lives within the Northern Sydney Central Coast Area Health Service Patient and/or carer/guardian consents to APAC service (Corwin et al, 2005) Have access to a phone (Corwin et al, 2005) Able to have treatment delivered in a safe environment (Howden & Grayson, 2002) Has designated Medical responsibility for the clinical management of the patient for the duration of treatment from the APAC service Is able to be reviewed by Medical management either by returning to hospital or within the home (or designated safe environment). Patient is clinically stable (Howden & Grayson, 2002).

Patients residing outside the NSCCH Local Government Areas who no longer meet the criteria for APAC, will be transferred to appropriate services in consultation with the GP/Medical team. Planned/Unplanned Leave If the GP/Medical team has patients under their care and has to take planned or unplanned leave, they have to either: - Arrange an accredited APAC/GP Shared Care Locum or alternate Medical Management (when hospital team) to take over the patients clinical management. OR - Organise for the patient to be transferred to a hospital management team. 2. APAC referral criteria for Community Acquired Pneumonia If the patient meets the criteria outlined above a referral to APAC can be made by, a member of the Medical team, General Practitioner (GP), Nursing staff or Allied Health. Assess the patient, establish/accept ongoing clinical responsibility for CAP and be available for the duration of the treatment with the APAC service Complete in-patient medication chart with five to seven days orders for IV antibiotics. GPs complete the medication authority and fax to APAC together with and relevant pathology results (the original go home with the patient). Give prescription to patient for oral antibiotics (or any other relevant oral medications to be administered by APAC), if required The patient requires assessment by and authorisation from a SMS member, GP or Respiratory Physician before they will be accepted onto the APAC service Consideration must be given to the Pneumonia Severity Index (see Appendix) before the patient is admitted to the APAC service (usually patients at Category III). This is the responsibility of the treating physician. Patients may be excluded from APAC if critical vital signs in the 24 hours prior to referral to APAC: - Temp >38.5oC - Pulse rate >100/minute - Hypotension (100/50mm Hg or 30mm Hg < normal BP) (Micheal et al, 2006)
5

S:\Clinical & Operational Policies & Procedures/APAC Protocols/Pneumonia 7/06/2007

According to Ewig et al, (2004), hospital admission should be considered if the patient has any of the following: Temperature (T) < 35C or 38.50 - 40C+ Heart Rate (HR) >125/min Respiratory Rate (RR) >30/min Systolic BP <90mmHg and/or Diastolic BP <60mmHg New and/or significant confusion

Patient Diagnosis and Assessment Requirements

1. History History of presenting illness: symptoms, duration and prior treatment. Co-morbidity: chronic obstructive pulmonary disease (COPD), diabetes, renal failure, cardiac failure, liver disease, prior hospitalisation, confusion, malignancy and ethanol. Current medications and allergies Social factors including geography, accessibility, support of carers and family. Recent pneumoccocal and/or influenza vaccine 2. Baseline Investigations (to be taken before patient begins intravenous antibiotics, unless recent results available)

FBC, ESR, EUC, LFT, CRP, blood glucose) If temperature constantly >38oC or vital signs are abnormal, blood cultures may be required Radiology/imaging - may be required Chest x-ray (posteroanterior and lateral) is essential to confirm diagnosis and eliminate pleural effusion. VQ and /or CT scan is sometimes considered ECG Serum to store for atypical pneumonia serology Arterial blood gases - if appropriate. Microbiology Sputum Specimen

3. Examination (additional to temp., HR, RR, BP & mental state) Cardiac, respiratory and abdominal examination O2 saturations on room air and oxygen Auscultation Peak flows/spirometry in patients with a history of COPD, asthma or smoking Other relevant signs documented

General Care
1. APAC Encourage patients to drink at least 1,5L per day unless contraindicated by comorbidities Monitoring of medical condition and potential complications Clinical response means: 1) Temperature < 37.8oC for 24 hours (if greater than this at admission)
6

S:\Clinical & Operational Policies & Procedures/APAC Protocols/Pneumonia 7/06/2007

Education re. self-management strategies. Assess patients progress and coping mechanisms Improve exercise tolerance Prevent disease recurrence Monitor pharmacotherapy Support early discharge of patients admitted to the hospital setting with CAP who are medically stable and progressing well. Prevention of hospitalisation for patients who would otherwise need treatment as an in-patient. Provide support and treatment for patients with an infective exacerbation of chronic obstructive pulmonary disease (COPD). Refer to APAC clinical guidelines for management of COPD. Assessment of precipitating factors for admission to hospital and implementation of strategies to prevent re-admissions. Communication with Medical Officers as required Allied Health services, Occupational Therapy, Physiotherapy, Pharmacy and Social Work advice (Howden & Grayson, 2002). If an in-patient, APAC Registered Nurse should complete the APAC Admission prior to discharge. If patient is referred from GP, APAC staff member will complete the APAC admission on the first home visit to the patient.

Once referral and admission are confirmed with APAC, the first home visit be conducted within 24 hours. APAC Multi-disciplinary team: Physiotherapists. Occupational Therapists. Respiratory Clinical Nurse Specialist. Pharmacist. Registered Nurses. Community Care Aids. Social Worker Access to a Clinical Psychologist

2. Carers and Families: Patients and families should be given information and feedback on the progress of the diagnosis of pneumonia. It needs to be recognised that by the patient returning home, families may experience stress and they may require emotional support. Carers should receive all necessary equipment and training in moving and handling the patient safely within the home environment.

3.

SMS/GP Clinical Management Establish good IV access for in-patients. Inform APAC, if patient requires IV access when patient is referred from GP Complete Hospital discharge letter if patient an in-patient

Medical Review Regular review every 2-3 days (at least) Re-ordering of medications on appropriate medication chart by attending Medical
7

S:\Clinical & Operational Policies & Procedures/APAC Protocols/Pneumonia 7/06/2007

team/GP. Updating of treatment care plan in the patients APAC health care file. 4. Criteria for Transfer to the Emergency Department or GP Review Vital signs indicate severe illness Impaired mental status Respiratory rate < 30/min Blood pressure (SBP <90mmHg or<60mmHg) Any new problem needing prompt medical assessment. Drug reaction so review of antibiotic therapy is required.

Ref.: American College of Chest Physicians, 2004

NOTE: If a patient requires transfer to the Emergency Department, the treating Medical team or GP should be contacted after the review by Emergency Staff.

Treatment Options The rationale for antibiotic guidelines for CAP is to optimise outcomes and to minimise
resistance at a reasonable cost to the patient and health care system. Recent individual study results do not reveal significant differences in efficacy between various antibiotics and antibiotic groups. (Burke A 2004). APAC treatment guidelines are based on Therapeutic Antibiotic Guidelines 13th edition 2006, the RNSH Antibiotic Treatment of Some Infections, and as per order of the treating Physician. For pneumonia caused by unusual pathogens, it is recommended that the treating physician consult an Infectious Diseases Specialist to determine the required medication regimen Consideration is also given to the patients Pneumonia Severity Index (PSI) score and medical condition - Refer to Therapeutic Guidelines: Respiratory 2005 (see Appendix) and Institute for Clinical Systems Improvement (ICSI) 2005 for calculation of Pneumonia Severity Index (PSI). The majority of patients requiring intravenous antibiotics are treated with the a third generation cephalosporin and a macrolide antibiotic for a minimum of 5 days. Medications used for APAC patients (unless otherwise specified) include GP Directed Care Ceftriaxone 1 g daily intravenous (PBS Restricted Benefit: Infections where positive bacteriological evidence confirms that this antibiotic is an appropriate therapeutic agent.) with - Roxithromycin 150mg BD or 300mg orally daily or - Doxycycline 100mg orally, BD for 7days or - Clarithromycin 500mg orally, BD for 7 days In-patient, SMS/VMO Directed Care Ceftriaxone 1g daily (IVI) (Therapeutic Antibiotic Guidelines, 2006) Roxithromycin 150mg BD (PO) or 300mg (PO) daily (Therapeutic Antibiotic
8

Guidelines, 2006) S:\Clinical & Operational Policies & Procedures/APAC Protocols/Pneumonia 7/06/2007

On medical review, the intravenous antibiotics may be ceased and oral antibiotics commenced in accordance with the Therapeutic Guidelines: Respiratory 2005 and The CAPTION Project (National Prescribing Service 2005)

APAC Documentation
A comprehensive record of all patient contact, direct and indirect, including communication with the patients SMS/GP or any other health representative, must be documented in the patients Health Care File within 24hrs of the patient contact. Patients clinical condition at each visit must be documented Official APAC documentation should be used and completed as required Each page of documentation must be headed with the patients name, date of birth and medical record number. Each entry into the patients medical records must be dated, timed, and have the attending health care workers signature, first initial and surname, and employee identifying number.

Discharge Process
For patient discharge from APAC there should be: Full physical medical review from the treating SMS/VMO or GP either in the patients home/hostel/nursing home, doctors consultation rooms or hospital emergency department. Notes improvement in clinical parameters, patients condition, and if required laboratory/imaging results. Decisions regarding duration of continuing oral antibiotic therapies are made and a followup appointment with the treating Specialist or GP is arranged +/- a follow-up chest X-ray. If a patient has not been managed by the GP, they will be referred back to their GP, (regardless of their involvement in Clinical management while with APAC), with details of their APAC admission and ongoing medical needs. APAC discharge letter and documentation is to be completed. Patient is referred to community services as appropriate.

S:\Clinical & Operational Policies & Procedures/APAC Protocols/Pneumonia 7/06/2007

APAC/GP Shared Care Community Acquired Pneumonia Flow Chart

GP REVIEWS PATIENT

DIAGNOSIS

CONFIRMED PNEUMONIA

NO PNEUMONIA

TREAT AS APPROPRIATE

MEETS APAC CRITERIA:

REFER TO APAC SERVICE - 7am- 11pm

Central Coast PH: (02) 4320 3482

NO

FAX: (02) 4320 3555

Northern Sydney - PH: 0421 582 997

FAX: (02) 9926 5997 The pneumococcal urinary antigen assay can be performed either before or after commencing treatment to identify the pathogen. It is advised that a chest X-ray is performed within 48 hrs of commencement of treatment

YES

REFER TO PNEUMONIA SEVERITY INDEX*

Ceftriaxone 1g Daily With Roxithromycin 150mg BD or 300mg daily 7 days or Doxycycline 100mg BD 7 days or Clarithromycin 500mg BD 7days

NB*: Please refer to APAC GP Shared Care Clinical Guidelines for Home Management of Community Acquired Pneumonia

S:\Clinical & Operational Policies & Procedures/APAC Protocols/Pneumonia 7/06/2007

10

References
Bartlett JG, Dowell SF, Mandell LA, File TM, Musher DM, Fine MJ. Practical guidelines for the management of community-acquired pneumonia in adults. Infectious Diseases Society of America. Clinical Infectious Diseases 2000 31:347-382 Bjerre LM, Verheij TJM, Kochen MM. Antibiotics for community acquired pneumonia in adult outpatients. The Cochrane Database of Systematic Reviews 2004, Issue 2. Burke AC. Empiric therapy of community-acquired pneumonia. Chest 2004;125:1913-1919 BTS guidelines for the management of community-acquired pneumonia in adults. Thorax 2001;56 (4):1-64 Corwin P, Troop L et al (2005) Randomised controlled trial of intravenous antibiotic treatment for cellulitis at home compared with hospital, BMJ;330:129 (15 January), doi:10.1136/bmj.38309.447975.EB Ewig S, de Roux A, Bauer T, Garcia E, Mensa J, Niederman M, Torres A. Validation of predictive rules and indices of severity for community-acquired pneumonia. Thorax 2004;59:421-427 File TM. Community-acquired pneumonia. Lancet. 2003;13:362(9400):1991-2001. File TM Jr, Garau J et al. Guidelines for empiric antimicrobial prescribing in community-acquired pneumonia. Chest 2004;125(5):1888-901. Degelau J. Institute for Clinical Systems Improvement (ICSI) Health Care Guideline. Communityacquired pneumonia in adults. ICSI 2005;6. Howden, Benjamin P and Grayson, M Lindsay (2002), Hospital-in-the-home treatment of infectious diseases, Medical Journal of Australia 6 May 176(7): 440-445 Johnson Paul D R, Irving Lou B, Turnidge John D Community-acquired pneumonia MJA 2002 (176) (7): 341-3 Mandell LA, Bartlett JG, et al. Update of practice guidelines for the management of communityacquired pneumonia in immunocompetent adults. Clin Infect Dis 2003;37(11):1405-33 Marrie TJ, Beecroft MD, Zelkja H-G. Resolution of symptoms in patients with community-acquired pneumonia treated on an ambulatory basis. Journal of Infection 2004;49:302-309. Marie TJ, Lau CY, Wheeler SL, Wong CJ, Vandervoort MK, Feagan B. A controlled trial of a critical pathway for treatment of community -acquired pneumonia. JAMA 2000;283(6):749-755 Michael F, Murphy T, Graham A.D. Lippincott Manual of Nursing Practice 2006, 8th Edition Lippincott Williams & Wilkins, Philadelphia Mosby-Year Book, Inc. Mosbys Medical, Nursing & Allied Health Dictionary. 1998, 5th Edition. St Louis, Missouri 63146, USA. National Prescribing Service : CAPTION Project, 2005 (www.nps.org.au) Niederman MS, Mandall LA, Anzueto A. Guidelines for the management of adults with community acquired pneumonia. Diagnosis, assessment of severity, anti microbial therapy, and prevention. American Journal Respiratory Critical Care Medicine 2001;163:1730-1754. Ramsdell J, Narsavage GL , Bolton FP, Fink JB (2005) Management of community-acquired pneumonia in the home: an American College of Chest Physicians clinical position statement. Chest 2005;127(5):1752-1763. Royal North Shore Hospital, NSCCH, Antibiotic Treatment of Some Infections 2005
S:\Clinical & Operational Policies & Procedures/APAC Protocols/Pneumonia 7/06/2007 11

Therapeutic Guidelines: Antibiotic, Version 13, 2006. Therapeutic Guidelines Limited, North Melbourne, Victoria 3051 Australia Therapeutic Guidelines Limited: Respiratory Version 3, 2005. Therapeutic Guidelines Limited, North Melbourne, Victoria 3051 Australia

Acknowledgments:
APAC NSCCHS APAC/GP Shared Care Dr Chris Duggan Ms Nicole Mangone Professor Christopher Dennis Clinical Guideline for the Management of Community Acquired Pneumonia Clinical Guideline for the Management of Community Acquired Pneumonia Head of Respiratory Medicine Gosford Hospital, NSCCH Respiratory CNC, NSCCH Head of Department Respiratory Medicine, RNSH,

Dr Helena Miksericius

Division of GPs, Central Coast

Manly Warringah Division of General Practice Central Coast Division Of General Practice GP Consultant GP Collaboration Unit Barbara Levin Jane Whitehurst Nicholas Marlow Jairo Herrera Emma Floyd Felicity Jenkins APAC Pharmacist NSCCAHS APAC Clinical Nurse Consultant NSCCH APAC Area Manager NSCCHS APAC / GP Shared Care Project Coordinator APAC Clinical Nurse Educator, NSCCH APAC Clinical Nurse Specialist NSCCH

The original policy was originally ratified in 2000 by: Dr Christopher Dennis - Head Dept Respiratory Medicine, Royal North Shore Hospital Dr Christopher W. Clarke - Consultant Thoracic Physician, Ryde Hospital Dr Stan Braude - Pulmonary and Critical Care Medicine, Manly Hospital Dr Jack Delohery - Director of Aged Care Services, Mona Vale Hospital Dr Michael Dodd - Head Respiratory Department, Hornsby Hospital

Authorisation Stamp Document Owner: - APAC NSCCH Revised: Email: -

Version: - 3 Facility: - APAC NSH Phone: - 9926 7292

Document Number: Authorised by: - APAC Protocol Committee th 17 February 2006 Last Modified: - 7 June 2007

S:\Clinical & Operational Policies & Procedures/APAC Protocols/Pneumonia 7/06/2007

12

Appendix

S:\Clinical & Operational Policies & Procedures/APAC Protocols/Pneumonia 7/06/2007

13

MRN: FAMILY NAME:

DOB:

ACUTE / POST ACUTE CARE RESPIRATORY CARE PLAN

Medication
BD/D First dose (date/time)

FIRST NAME: ADDRESS:

Dr. ordering medication: Contact details: CODES V: Variance (See Notes) N/A: Not Applicable Transport: CCA or P: Private Last dose (date/time) Review (date/time) Review (place)

Y: Yes

N: No Transport arranged Initial

Dr reviewing

Date
Time Day since APAC admission H/L assess/plan/review APAC policies/procedures SMS review GP review

Administer IV medications
Observations Temperature Pulse rate/strength/regularity Blood pressure Respiratory rate

O2 Saturation on room air (RA) at rest O2 Saturation _____Lpm at rest Desaturation post exercise____m___Lpm Desaturation post exercise_____m RA

GMR
Bowels open Voiding issues

scale (0-10) Pain Site Type Analgesia Weight Dyspnoea Borg RPE (0 10) PTO Rest Borg RPE (0 10) Exertion FEV1 Peak Expiratory Flow Rate Air Entry & Breath sounds
C: Crackles W: Wheeze AW: Audible Wheeze L: Left R: Right >:Greater than <: Less than =: Equal

P: Peripheral C: Central Cyanosis Peripheral Oedema H: Hands L: Legs F: Feet Describe affected area (mild, moderate, severe) Cough
S: Strong or W: Weak D: Dry or M: Moist E: Effective or I: Ineffective

Sputum

Amount Colour Consistency

Print name Sign Designation (PTO)

S:\Clinical & Operational Policies & Procedures/APAC Protocols/Pneumonia 7/06/2007

14

MRN: FAMILY NAME:

DOB:

ACUTE / POST ACUTE CARE RESPIRATORY CARE PLAN (CONTD)

Date Medications Oral Corticosteroids Antibiotics (PO/IV) Distance Conditioning in no. of repetitions

FIRST NAME: ADDRESS:

CODES V: Variance (See Notes) N/A: Not Applicable Transport: CCA or P: Private

Y: Yes

N: No

Exercis e Toleran ce
Fluid/Diet intake

F: Fluid intake amount FR: Fluid restriction amount D: Number of meals S: Supplements (type) IVC insertion date IVC site IVC Removed Scalp vein Dressing attended
Chronic Respiratory Disease Care Plan attended Respiratory Nurse consult

Medication supervision
Psycho-social assessment Rest/activity education Equipment/drug Check Length of visit in minutes Print Name Sign Designation

occasion of service record for allied health and rn

Date Time Administer IV medication Temperature Pulse rate/ strength/ regularity Blood pressure Respiratory rate O2 saturation RN PH PT/OT SW/CCA Medication supervision Length of visit in minutes Print Name Sign Designation

S:\Clinical & Operational Policies & Procedures/APAC Protocols/Pneumonia 7/06/2007

15

CLINICAL PATHWAYS FOR CHEST INFECTION

Prior to APAC Admission
Medical management defined, and length of treatment prescribed. Review plan arranged APAC policies, visiting times and procedures explained: patient given APAC brochure. Diagnosis and treatment explained to patient/carer, including instructions to monitor for deterioration and actions if any concerns Patient consents to treatment, medical management and individual care plan IV access established and secured safely if appropriate and patient educated re IVC, Including complications and showering instructions. Provide copies of recent pathology results, ABGs, investigations and spirometry in APAC file. Complete Respiratory Worksheet assessment on pages 2-3. If a chronic respiratory background is present ensure a Chronic Respiratory Care Plan is present in notes; refer to Respiratory Nurse and appropriate Allied Health Professionals. Devise treatment plan involving interdisciplinary team and set goals re length of APAC involvement and referral to ongoing services if required. Ensure patient has adequate and correct medication supply and assess patients pharmaceutical knowledge. Psychosocial needs assessed and addressed. Carer involved if appropriate.

First Visit (Day One)

APAC visiting times, policies and procedures reinforced. Education re condition and treatment continued with patient and carer. Ensure patient has adequate and correct medication supply and assess patients pharmaceutical knowledge. Ongoing assessment and support of general condition. Treatment given according to care plan. Establish pre-illness functional level and aim to return to this level and quality of life by addressing care issues outlined in APAC respiratory care plans. If the patient has a chronic respiratory background, address any issues by completing the Chronic Respiratory Disease Care Plan at each visit. Advice given re ACBT and handout given. Assessment of coping abilities, support and understanding of illness. Encourage self-management. Organise services/equipment required to aid returning to independent state. Assess use of home oxygen; complete oxygen checklist (if applicable). Changes to condition and treatment documented and reported to doctor and the APAC Clinical Coordinator if required.

Ongoing Visits (Day 2 - 5)

Continue treatment as per plan, and reinforce support / education as per day 1. Ongoing assessment if general condition by allied health professionals /respiratory nurse if required. Expect general improvement by day 3 5; if no improvement, facilitate review with the doctor responsible for care. Educate regarding self - management techniques if the patient has a background of a chronic respiratory disease, and continue to update Chronic Respiratory Disease Care Plan.

Discharge Planning (at reviews)

Liaise with the doctor reviewing the patient and the APAC respiratory team and keep the patient and carer informed of the expected outcome and treatment duration. Ensure Chronic Respiratory Disease Care Plan has been completed if appropriate. Document all updates clearly in patient records and inform the APAC Clinical Coordinator of plan. Discuss NSHNS and Pulmonary Rehabilitation options, and provide Breathe Program brochure and refer patient if appropriate. Ensure all data is collected on Respiratory Worksheet, attend MRC Dyspnoea Scale on discharge.

Expected Outcome (Day 10 14)

Patient is reviewed by the doctor responsible for their care or an advocate, condition has resolved to the point of not requiring APAC support. Patient care is transferred from APAC to the care of allocated medical officer and/ or community services (eg: Breathe Program) if required.

Variance

Patient not improving Patient develops new issue Patient deteriorated

Action: patient reviewed and care plan altered. Action: patient reviewed and care plan altered. Action: patient reviewed and care plan altered. 16

S:\Clinical & Operational Policies & Procedures/APAC Protocols/Pneumonia 7/06/2007

Patient classification using Pneumonia Severity Index (PSI)

Johnson Paul D R, Irving Lou B, Turnidge John D Community-acquired pneumonia MJA 2002 (176) (7): 341-3

PSI risk class I (lowest risk). Patient has none of the following: Age > 50 years; History of neoplastic disease, congestive cardiac failure, cerebrovascular, renal or liver disease; or Clinical signs altered mental state, pulse rate 125 per minute, respiratory rate 30 per minute, systolic blood pressure < 90 mmHg, or temperature < 35C or 38.50 - 40C+. PSI risk classes IIV. Patients with any of the above characteristics are classified according to their PSI score, calculated according to the table below.

Calculation of PSI risk score

Factor Patient age Nursing home resident PSI score Age in years (male) or age 10 (female) +10

Coexisting illnesses
Neoplastic disease Liver disease Congestive cardiac failure Cerebrovascular disease Renal Disease +30 +20 +10 +10 +10

Signs on examination
Altered mental state Respiratory rate 30 per minute Systolic blood pressure < 90 mmHg Temperature 35C or 40C Pulse rate 125 bpm +20 +20 +20 +15 +10

Results of investigations
Arterial pH < 7.35 Serum urea level 11 mmol/L Serum sodium level < 130 mmol/L Serum glucose level 14 mmol/L Haematocrit < 30% Po2 < 60 mmHg or O2 saturation < 90% Pleural effusion +30 +20 +10 +10 +10 +10 +10

S:\Clinical & Operational Policies & Procedures/APAC Protocols/Pneumonia 7/06/2007

17

Management of Community Acquired Pneumonia in Adults using the Pneumonia Severity Index (PSI) (Therapeutic Guidelines Respiratory Version 3 2005)

Management of Community Acquired Pneumonia in Adults using the Pneumonia Severity Index (PSI) (Therapeutic Guidelines Respiratory Version 3 2005)

S:\Clinical & Operational Policies & Procedures/APAC Protocols/Pneumonia 7/06/2007

18