This is the current release of the guideline.

Community-acquired pneumonia (CAP)

Diagnosis
Evaluation
Management
Risk Assessment
Treatment

Emergency Medicine
Family Practice
Infectious Diseases
Internal Medicine
Pulmonary Medicine

Advanced Practice Nurses
Health Plans
Managed Care Organizations
Physician Assistants
Physicians

To address the requirements for successfully managing patients with community-acquired pneumonia (CAP) in the home environment

Immunocompetent adults with community-acquired pneumonia (CAP) who are living at home or in unskilled residential facilities:

• Previously healthy individuals and chronically ill individuals who may or may not be home-bound but choose not to go into the hospital
• Hospitalized patients with CAP who are completing a hospital discharge plan

Note: These recommendations are not intended to be applied to pediatric patients, patients with human immunodeficiency virus (HIV) or other forms of immune compromise, or patients living in skilled nursing facilities.

1. Initial evaluation and diagnosis performed in person  by a qualified provider (i.e., physician, nurse practitioner, or physician assistant)
2. Determination of site of care
3. Administration of first dose of antibiotic, oxygenation, and hydration within 8 hours of presentation
4. Treatment with antibiotic regimen based on empiric therapy guidelines of the American Thoracic Society (ATS) and Infectious Disease Society of America (IDSA)
5. Transfer to acute care facility if patient care contract cannot be agreed to or is violated
6. Repeat assessment within 24 hours for high-risk patients
7. Closure visit
   • Evaluation of risk of recurrence
   • Discussion of preventive measures
   • Assessment of functional status
8. Chest radiography (a minimum of 8 weeks following diagnosis)

• Risk of infection with pathogenic bacteria
• Mortality
• Response to treatment
• Antibiotic resistance

Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

This clinical position statement is based on a review of the guideline literature and on a consensus panel meeting of the American Academy of Home Care Physicians (AAHCP) Community-Acquired Pneumonia Working Group (see Appendix 2 of the original guideline document for a list of participants), which was held on October 20, 2000, in Coolfont, WV. The AAHCP panel review process included reviews of guidelines from the American Thoracic Society (ATS) (1993), the Infectious Diseases Society of America (IDSA) (2000), the Canadian Infectious Diseases Society and the Canadian Thoracic Society (2000), the Centers for Disease Control and Prevention (2000), the European Respiratory Society (1998), and the British Thoracic Society (BTS) (1993). The AAHCP recommendations were reconsidered by the American College of Chest Physicians (ACCP) working group and were updated with a MEDLINE search of the literature from October 2000 to July 2003. This review included the 2001 update of the American Thoracic Society recommendations and the 2003 update of the IDSA recommendations.

Not stated

Expert Consensus (Committee)

Not applicable

Review

Not stated

Expert Consensus

This clinical position statement was developed by a working group of the American College of Chest Physicians (ACCP) Home Care Network, which includes representatives of the American Thoracic Society (ATS) and the American Association of Respiratory Care.

The working group concluded that the current literature did not provide the scientific evidence to support a clinical practice guideline as defined by the ACCP (i.e., a statement that is based on scientific evidence, that explicitly documents the process used to develop the statement, and that grades the strength of the evidence used in making clinical recommendations). Because the issue of appropriate resources for the home treatment of community-acquired pneumonia (CAP) is of immediate importance, the working group proceeded to develop this clinical position statement. None of the current guidelines that address the management of patients with community-acquired pneumonia specifically focuses on practice recommendations for the home care patient, but the recommendations in this position statement are compatible with each of these existing guidelines.

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

External Peer Review
Internal Peer Review

Each chapter of this guideline was reviewed and approved by the American College of Chest Physicians (ACCP) Health and Science Policy Committee prior to submission, approval by the ACCP Board of Regents, and approval by the American Academy of Home Care Physicians (AAHCP). The guideline was then forwarded to other external organizations for endorsement.

Recommendations for the evaluation of care provided to the immunocompetent adult patient with community-acquired pneumonia (CAP) who is being treated at home or in an unskilled residential facility are summarized below. Future research should be focused on evidence for appropriate assessment and in-home treatment, such as diagnostic tests, home care interventions, and the exploration of the efficacy of telephone triage in selected groups of patients who are at low risk and are well-known to the provider. Finally, the approach to the in-home management of CAP that has been outlined herein, and others, should be studied to assess their impact on patient outcomes (especially in the elderly) and to ensure that in-home management can achieve the same level of quality and patient outcomes as at any other treatment site for appropriate patient subsets.

Recommendations for the Home Treatment of Patients with CAP

Initial Patient Evaluation and Diagnosis in the Home Environment

1. A qualified provider includes a physician, nurse practitioner, or physician assistant.
2. The initial evaluation should be performed in person by a qualified provider or by a visiting home nurse who is in contact with a qualified provider at the time of the evaluation. In this case, the qualified provider must evaluate the patient within 24 hours of the initial diagnosis. Telephone triage alone is not acceptable.
3. If a qualified provider does not meet with the patient at the time of the initial evaluation, the provider must see the patient sometime between presentation and closure.

Determination of Site of Care

4. Home care should be an option if it can provide the same level of quality and achieve the same level of recovery and functional status, consistent with the patient's wishes and overall treatment goals, as would be possible at any other site of care.
5. Care should be provided in a timely fashion. If these goals cannot be achieved in the home care setting, transfer to an acute care facility should be considered.
   • The first dose of antibiotic should be administered within 8 hours of presentation.
   • Oxygenation should be optimized within 8 hours of presentation.
   • Hydration should be initiated within 8 hours of presentation.
6. If a patient care contract cannot be agreed to or is violated, transfer to an acute care facility should occur.

Management of CAP at Home

7. The patient should be treated with antibiotics based using the empiric therapy guidelines of the American Thoracic Society (ATS) and Infectious Disease Society of America (IDSA).

Monitoring and Goals for Nurses Providing Interim Home Care

8. Repeat assessment should be performed within 24 hours for the high-risk patient.
9. If a provider chooses not to refer a patient to a home care agency, the standards for interim care must still be met.

Closure

10. There should be a closure visit for each patient during which the risk of recurrence is evaluated, preventive measures are discussed, and functional status is assessed.
11. A chest radiograph should be obtained to confirm the resolution of the illness a minimum of 8 weeks following diagnosis.

None provided

The type of evidence supporting the recommendations is not specifically stated. The recommendations are based on a review of the guideline literature and on a consensus panel meeting of the American Academy of Home Care Physicians (AAHCP) Community-Acquired Pneumonia Working Group.

Successful management of patients with community-acquired pneumonia in the home environment would provide the same level of quality and achieve the same level of recovery and functional status as would be possible in any other site of care.

Not stated

• The information provided in this statement should be used in conjunction with clinical judgment. These recommendations may not apply to every individual patient; therefore, it is important for the physician to take into consideration the role of patient preferences and the availability of local resources.
• The American College of Chest Physicians (ACCP) is sensitive to concerns that nationally and/or internationally developed position statements are not always applicable in local settings. Further, recommendations are just that: recommendations, not dictates. In treating patients, individual circumstances, preferences, and resources do play a role in the course of treatment at every decision level. These recommendations are intended to guide healthcare decisions and may be adapted to be applicable at various levels.

An implementation strategy was not provided.

Getting Better

Effectiveness
Patient-centeredness
Timeliness

Not applicable: The guideline was not adapted from another source.

2005 May

American Academy of Home Care Physicians - Professional Association
American College of Chest Physicians - Medical Specialty Society

American College of Chest Physicians

American College of Chest Physicians' Home Care Network Working Group

Primary Authors: Joe Ramsdell, MD, FCCP, Department of Medicine, University of California, San Diego, Medical Center, San Diego, CA; Georgia L. Narsavage, PhD, RN, CS, Francis Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH; James B. Fink, MS, RRT, Aerogen

Work Group Members: Joe Ramsdell, MD, FCCP; Ann Cathcart, MSW, RSW; Georgia L. Narsavage, PhD, RN, CS; Nicholas S. Hill, MD, FCCP; James B. Fink, MS, RRT; Joe Lewarski, RRT; Barry Make, MD, FCCP

It is essential that the American College of Chest Physicians (ACCP) have full disclosure of outside interests from those individuals serving on policy development committees, including liaison representatives from outside organizations. Both real and potential conflicts of interest may actually affect impartial or objective decisions or may appear to.

No conflicts are reported in the original consensus document.

This is the current release of the guideline.

None available

None available

This NGC summary was completed by ECRI on July 26, 2005. The information was verified by the guideline developer on July 26, 2005.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.