Care Process Model DECEMBER 2013

DIAGNOSIS AND MANAGEMENT OF Acute () 2013 update

This care process model (CPM) is produced by Intermountain Healthcare’s Lower Team, a workgroup of the Primary Care Clinical Program. The CPM provides best-practice recommendations for differential IN THIS UPDATE? diagnosis and management of acute cough and bronchitis. WHAT’S NEW Germ Watch is available at • New data showing an upward trend in unnecessary KEY POINTS intermountainphysician.org use of for treatment of acute bronchitis — • Diagnosis of acute bronchitis should be made only after ruling reinforcing our need to do better! out other sources of cough — including , , , pertussis, • Updated information on , and acute exacerbations of chronic bronchitis (AECB). 1 The algorithm on pages 2 and 3 influenza, and pertussis testing and treatment, guides that evaluation and diagnostic process. Local infection surveillance programs such as with links to more information. Germ Watch can provide up-to-date information about communicable diseases that routinely • Summary of evidence base for symptom affect our communities. relief of acute cough (see ACUTE BRONCHITIS • If acute bronchitis is the diagnosis, antibiotics are TREATMENT RECOMMENDATIONS box inside). Unnecessary Use NOT the answer! Despite ongoing evidence that antibiotics • New and revised provider and patient NOT are needed for acute bronchitis, latest data show that their % of adults with acute bronchitis who received an antibiotic education materials to support in prescription within 3 days of office visit (based on SelectHealth data) use is actually increasing. SelectHealth rates rose from 70% in and evidence-based treatment 2008 to nearly 75% in 2010 (see graph at right), which mirrors 76 74.87% of acute cough (bronchitis) and related illnesses. the national trend. 2,3 Unnecessary antibiotic use increases risk 75 for disease complications related to drug-resistance , 74 and increases healthcare costs. 73 GOALS 72 71% • 71 The goal is to Help providers improve accuracy of • Withholding antibiotics has no significant effect cent % 70.15% r 70 reverse this diagnosis of acute bronchitis and other lower on patient satisfaction or return visits. Studies Pe 69 respiratory tract . show that education efforts and the time a healthcare provider trend! 68 spends with the patient are the biggest determinants of patient • Reduce the unnecessary use of antibiotics 4,6 67 satisfaction results. See the ACUTE BRONCHITIS TREATMENT 2008 2009 2010 for treatment of acute bronchitis, RECOMMENDATIONS box in the algorithm inside for tips Years thereby sparing patients the additional risks and on communicating with patients about cough illnesses and associated costs. antibiotic resistance. % of adults with acute bronchitis who received an antibiotic prescription within 3 days of office visit (based on SelectHealth data)

The inside pages of this tool provide 76an algorithm and associated notes, and can be folded open and posted in your office or clinic. 74.87% The back page summarizes vaccine recommendations,75 references, and resources. 74

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67 2008 2009 2010 Years DIAGNOSIS AND MANAGEMENT OF

Acute Cough (Bronchitis)

(a) ACUTE COUGH/BRONCHITIS symptoms: Patient presents with • Acute bronchitis is defined by the CDC as an“ acute ACUTE COUGH (BRONCHITIS) symptoms (a) respiratory infection with a normal that is manifested by cough with or without production that lasts for up to 3 weeks.” 1,4 See Intermountain’s Possible PNEUMONIA (b)? Chest (b) PNEUMONIA is NOT likely if all of the following are absent:1 YES x-ray POSITIVE Pneumonia CPM • 37.8°C (100°F) or greater • O2 sat 88% or less Care Process Model FEBRUARY 2012 Available on the DIAGNOSIS AND MANAGEMENT OF Community Acquired Pneumonia (CAP) • • February 2012 update Heart rate 100 bpm or greater Focal rales

This care process model (CPM) is produced by Intermountain Healthcare’s Lower Respiratory Tract Infection Team, a subgroup of the Primary Care Clinical Program. The CPM summarizes and updates evaluation and treatment WHAT’S NEW IN THIS UPDATE? recommendations for community-acquired pneumonia (CAP) in immunocompetent patients 18 years and older, though Pneumonia topic page at many of the recommendations also apply to younger patients. Recommendations are based on recent local susceptibility • Updated antibiotic sensitivity data and shortened length of antibiotic treatment. NO data and practice patterns, along with the most recent consensus guidelines of the Infectious Diseases Society of America Azithromycin is recommended for 3 days, levofloxacin 1 and the American Thoracic Society. The guidelinesdo NOT apply to health-care-associated pneumonia (HCAP). for 5 days, and other antibiotics for 7 days unless cavitation, empyema, or extra-pulmonary disease are present. See algorithm on page 2. • • WHY FOCUS ON PNEUMONIA? • Clarification and emphasis on timing of • Pneumonia remains common, serious, and costly. In the U.S., pneumonia is the 8th leading cause of death overall, Respiratory rate 24 or greater Decreased breath sounds blood cultures and antibiotics. the 5th leading cause of death over age 65, and the 2nd leading reason for hospitalization of Medicare patients.2,3 See algorithm on page 2. 1,4,5 NEGATIVE Treatment costs for pneumonia are estimated at $10 billion per year. • Vaccination reminder. Continued emphasis on importance of influenza and pneumonoccal vaccines • Site-of-care decisions can dramatically affect mortality and cost of care. The cost of inpatient care for pneumonia intermountainphysician.org/ before discharge. is up to 25 times greater than the cost of outpatient care,4 representing most of the estimated $10 billion in yearly 1,4 • Updated order sets, both paper and electronic, treatment costs. Although not hospitalizing sicker, higher-risk patients can result in higher mortality (both for patients to reflect changes to treatment recommendations. hospitalized after initial outpatient treatment6 and for severely ill patients not initially admitted to ICU7), patients at low risk for death treated in the outpatient setting are able to resume normal activity faster than if hospitalized.8,9 GOALS • Diagnosis and severity assessment cannot be made consistently and accurately using only the physical exam • Prompt and correct diagnosis, including a chest and clinical judgment. Chest x-ray should be performed whenever possible for diagnosis, and objective severity-of-illness x-ray whenever possible. scores (CURB-65) should be used to identify patients with CAP who are candidates for outpatient treatment.1,10 • Consistent use of objective severity-of-illness clinicalprograms • Antibiotics should be administered as early as possible. In-hospital mortality, length of stay, and 30-day mortality criteria (CURB-65) to guide site-of-care decisions. decrease when antibiotics are administered within 4 to 6 hours of diagnosis.3 Ideally, patients being admitted to the • Prompt administration of appropriate hospital for CAP should receive their first dose of antibiotics before they leave the emergency room or clinic.1 antibiotics (using CPM recommendations based on local sensitivity data) • Well designed and implemented local treatment guidelines decrease mortality and improve other clinical • Influenza and pneumococcal vaccines for all 11-14 outcomes. Data shows that Intermountain hospitals with the highest level of compliance with the pneumonia appropriate inpatients and outpatients. 11 : CPM and associated order sets have the lowest mortality rates. • Venous thromboembolism (VTE) prophylaxis (c) ASTHMA and early ambulation for all inpatients. The inside pages of this tool provide an algorithm and associated reference notes,

and can be folded open and posted in your office or clinic.The back page provides a discussion of antibiotic recommendation and a list of resources and references. • History of recurrent lower respiratory infection • History of recurrent wheezing and/or cough, especially at night • History of allergic or eczema See Intermountain’s Possible ASTHMA (c)? YES • Exertional dyspnea Asthma CPM • Variation of symptoms from day to day

Care Process Model AUGUST 2012 (minor update 5/13)

Available on the Asthma topic page at Management of Asthma 2012 Update

This care process model (CPM) was created by the Intermountain Healthcare’s Primary Care and Pediatric Specialty Clinical Programs. It summarizes clinical literature and provides expert advice regarding the diagnosis and management of asthma in pediatric and adult patients. This update builds on previous versions of Intermountain’s CPM as well as on theExpert Panel Report 3: Guidelines intermountainphysician.org/clinicalprograms for the Diagnosis and Management of Asthma (EPR-3), a 2007 publication of the National Heart, , and Blood Institute (NHLBI).1 7 What’s new IN THIS UPDATE? WHAT’S INSIDE Intermountain’s model remains closely aligned with the 2007 EPR-3 guidelines. This 2012 (d) RHINOSINUSITIS ALGORITHM ...... 2 update includes updated information on testing (exhaled nitric oxide and pulmonary function testing) and medication (formulations, dosages, prices) and highlights patient TREATMENT SUMMARIES and provider tools recently developed at Intermountain to support this standard of care. Ages 0 to 4 years ...... 4 Ages 5 to 11 years ...... 6 What’s happening AT INTERMOUNTAIN? Ages 12 years to adult ...... 8 Recent observations, results, and initiatives include the following: TRIGGER MANAGEMENT ...... 10 • Continued evidence for and focus on the use of daily controller medication. PATIENT AND Over the past two years, outcomes for asthma patients served by Intermountain continue to show a tight correlation between improved controller use and decrease in emergency FAMILY EDUCATION ...... 12 room utilization. MEDICATION TABLES ...... 13 • Measuring our management — and our patients’ outcomes. We currently track FOLLOW-UP ...... 15 1 Diagnosis. Bacterial rhinosinusitis is only likely if: controller use, beta-agonist use, inpatient admissions and emergency room visits for RESOURCES ...... 16 asthma, and education and discharge processes following pediatric inpatient admissions. Results of note are: NO – Controller use: GOALS We track the number of patients who filled controller prescriptions (without looking at how often they refilled their prescriptions). Using this approach, This CPM is part of a comprehensive care we are about 75% nationally on controller use. However, if we look at the number management system for asthma; its overall of patients who fill controllers consistently, we see much room for improvement. To address this, we plan a new measure (see next section of this discussion, below). goal is to help providers deliver the best clinical care in a consistent and integrated – ED visits and inpatient stays. Our ED use and inpatient stays have continued to way. Specific clinical goals are: – improve correlating with increased controller use. – Pediatric inpatient education and discharge. In 2010 and 2011, the Pediatric • Maintain near-normal lung function and Nasal purulence not improving after 7 days Specialty Clinical Program pursued board goals for improving the care provided activity level to children hospitalized with asthma. The first year we measured compliance with • Prevent symptoms and exacerbations providing (a) appropriate education to patients and families, and (b) an individualized by controlling the inflammatory process Asthma Action Plan on discharge. Our baseline was 50.4%; currently we are at 88% compliance. This year we aim to improve the appropriateness of controller medications • Reduce the need for short-acting prescribed on discharge by assessing level of chronic control and medication bronchodilators to twice a week or less compliance and then determining appropriate controller need from this information. • Minimize the need for ER visits and Our baseline rate was 62%; currently our rate is 88%. hospitalizations • Works in progress: new measures, new processes, new tools. • Provide optimal pharmacotherapy with – This year the Primary Care Clinical Program and SelectHealth are moving towards minimal or no adverse effects AND combining asthma care measures into a three-part “bundle” that will tell us how many patients (a) filled enough controller to last half of the year, (b) used excessive amounts of beta-agonists, and (c) had spirometry completed in a 2-year period. – The Pediatric Specialty Clinical Program has been involved in efforts to help patients and families maintain control of their asthma to avoid future readmissions to the hospital. These efforts have included developing and piloting a tool to track asthma control and treatment. So far at study sites, use of this tool has had a dramatic positive impact on readmission rates. – Unilateral facial or tooth pain or tenderness, or worsening after initial improvement 2 First-line treatment: amoxicillin 875 mg twice daily for 10 days • Treat with antibiotics only if signs and Possible RHINOSINUSITIS (d1)? YES symptoms are persistent or severe (d 1) 3 Treatment alternatives: – If prior treatment failure, high-dose amoxicillin-clavulanate • First-line antibiotic choice is amoxicillin (two 1000 mg XR tablets twice daily, dose based on 875 mg twice daily for 10 days (d 2) amoxicillin component) for 10 to 14 days NO For prior treatment failure, or penicillin – If allergic to penicillin, cefdinir 600 mg once daily x 10 days allergy, use alternatives (d 3) (e) Germ Watch is a local infection surveillance program accessible from the intermountainphysician.org home page. Rule out other conditions; consult Germ Watch (e) Germ Watch is available at intermountainphysician.org (f) INFLUENZA (www.cdc.gov/flu/professionals) 1 Symptoms. Influenza is likely if:

DIAGNOSIS – Sudden fever over 102°F / 39°C with a cough, , Possible INFLUENZA (f1)? YES • Consider influenza testing (f2) and or other respiratory symptoms antiviral treatment (f3) for patients AND who are within 48 hours of symptom – In onset, especially those at risk for 2 Testing. Consider influenza testing in these cases: NO influenza complications – If the results will change clinical care of the patient • Provide symptom relief and patient (e.g., use of antibiotics or antiviral medications, further education (see ACUTE BRONCHITIS diagnostic tests, homecare, etc.) TREATMENT RECOMMENDATIONS below). – If the results will influence clinical practice for other patients (e.g., confirm influenza circulation in the community, etc.) TREATMENT • • • • •

Diagnose asACUTEBRONCHITIS(ChestCold) Encourage prevention: Follow up Recommend symptomrelief: Educate patients.Tipsfortalkingwithpatients: Withhold antibiotics. . uncomplicated acutebronchitis,regardlessofdurationcough. – – Provideinformationaboutexpecteddurationofcoughandofferacontingency – Explainhowantibioticsincreasetheriskofantibiotic-resistanceinfections, – Refertocoughillnessasa“chestcold”ratherthanbronchitis. Identify andvalidatepatientconcernsspendtimeansweringpatientsquestions. – – – – Havepatientmakeafollow-upappointforneworworseningsymptoms, if – – –

Forfever,aches,andpains: (see below). plan ifsymptomsworsen.Recommendspecificsuggestionsforsymptomrelief which canbeserious. Provide Re-evaluate; Considerchestx-ray For coughrelief: For nasalcongestionandothercoldsymptoms: Patients canstillhavebronchialhyperresponsiveness for5-6weeks.Ifcough ineffective, andcough affectsqualityoflife,considerinhaled corticosteroids. Antibiotics arestillnotindicated.Consider trialofipratropium.Ifipratropiumis and pertussishasbeenruledout,consider diagnosisofpostinfectiouscough. lasts morethan3weeksandless 8weeks,andchestx-rayisnormal cough lastsformorethan3weekstotal(referpatienttotipsonthe varied significantly. remedies isdifficultduetolowqualityofmostclinicaltrialsortrialresultsthat be helpfulforassociatedsymptomsofcommoncold acetaminophen Possible AECB(acuteexacerbation of chronicbronchitis)- patient educationmaterialstoreinforcetheabove(atright). factsheetsforwhentocallthedoctor) Possible PERTUSSIS : may

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Vaccine recommendations (cdc.gov/vaccines/hcp/acip-recs/index.html) REFERENCES • Influenza.Annual is recommended for all patients over 6 months of age, but is particularly 1. Braman SS. Chronic cough due to acute bronchitis: ACCP evidence-based clinical practice recommendations. Chest. 2006;129(1Supp);95S-103S. http://chestjournal.org/ important for the following patients who are at increased risk for severe complications: cgi/content/abstract/129/1_suppl/95S. Accessed October 14, 2011. –– All children aged 6 months to 4 years (59 months) and all adults >50 years 2. QUALITY COMPASS® 2011. National Committee for Quality Assurance (NCQA) web site. http://www.ncqa.org/tabid/177/Default.aspx (password required to view data). –– Children and adolescents receiving long-term aspirin therapy at risk for Reye’s syndrome Accessed October 14, 2011. –– Women who will be pregnant during the influenza seasons 3. SelectHealth. Unpublished claims data, 2008-2010. 4. Gonzales R, Bartlett JG, Besser RE, et al. Principles of appropriate antibiotic use –– Adults and children with chronic pulmonary, CV, renal, hepatic, hematological, or metabolic disorders for treatment of uncomplicated acute bronchitis: background. Ann Intern Med –– Adults and children who have immunosuppression or any condition that can compromise respiratory function or 2001;134(6):521-529. 5. Gonzales R, Steiner JF, Maselli J, Lum A, Barrett PH Jr. Impact of reducing antibiotic the handling of respiratory secretions or that can increase the risk for aspiration prescribing for acute bronchitis on patient satisfaction. Eff Clin Pract. 2001;4(3):105-111. 6. Bateman K, Wallin A. Intermountain Healthcare Urgent Care Bronchitis Project. • Pneumonia. Pneumococcal vaccine is recommended for all patients 65 years old or older, as well as patients with Unpublished study, 1998-1999. serious long-term health problems and/or conditions that lower resistance to infections. All Alaskan Natives and 7. Anon JB, Jacobs MR, Poole MD, et al; Sinus And Allergy Health Partnership. Antimicrobial treatment guidelines for acute bacterial rhinosinusitis. Otolaryngol Head certain Native American populations should also be vaccinated. Vaccination is generally good for life, but a single Surg. 2004;130(1 Suppl):1-45. revaccination is recommended in the following cases: 8. Centers for Disease Control and Prevention. Acute cough illness (acute bronchitis) http://www.cdc.gov/getsmart/campaign-materials/info-sheets/adult-acute-cough- –– At age 65 or older, second dose is recommended if patient received first dose >5 years previously and was aged <65 illness.pdf. Accessed October 14, 2011. years at the time. If the first dose was given at age 65 or older, revaccination is not recommended. 9. Smith SM, Schroeder K, Fahey T. Cochrane Database of Syst Rev. Over-the-counter (OTC) medication for acute cough in children and adults in ambulatory settings. –– For immunocompromised patients between ages 2 and 64, second dose is recommended 5 years after the initial dose. 2008;(1):CD001831.doi:10.1002/14651858.CD001831. 10. Dicpinigaitis PV. Currently available antitussives. Pulm Pharmacol Ther. 2009;22(2): • Pertussis. Tdap vaccine is recommended as follows: 148-151 11. Dicpinigaitis PV, Gale YE, Solomon G, Gilbert RD. Inhibition of cough-reflex sensitivity by –– For individuals ages 11–64 years in place of one booster dose of the tetanus and diphtheria toxoids (Td) vaccines to benzonatate and guaifenesin in acute viral cough. Respir Med. 2009;103(6):902-906. provide added protection against pertussis, along with protection against tetanus and diphtheria. 12. Bolser DC. Cough suppressant and pharmacologic protussive therapy: ACCP evidence –– based clinical practice guidelines. Chest. 2006;129(1 Suppl):238S-249S. For pregnant women without updated pertussis vaccine during the late second trimester (after 20 weeks) or third 13. Dicpinigaitis PV, Spinner L, Santhyadka G, Negassa A. Effect of tiotropium on cough trimester, rather than immediately after delivery. reflex sensitivity in acute viral cough. Lung. 2008;186(6):369-374. –– 14. Smucy J, Becker LA, Glazier R. Beta 2-agonists for acute bronchitis. Cochrane For adults 65 years or older who have close contact with infants, or for anyone in this age group who desires the Database of Syst Rev. 2006;(4):CD001726. vaccines and has not previously received it. 15. Kim SY, Chang YJ, Cho HM, et al. Non-steroidal anti-inflammatory drugs for the –– For postexposure prophylaxis for all healthcare personnel who have contact with high-risk patients, regardless . Cochrane Database of Syst Rev. 2009;(3):CD006362. 16. Eccles R. Importance of placebo effect in cough clinical trials. Lung.2010;188 of vaccination status. Personnel who don’t have contact with high-risk patients can either receive postexposure (Suppl 1):S53-S61. prophylaxis or be monitored for 21 days after pertussis exposure and treated at the first onset of symptoms. 17. Braman S. Postinfectious cough: ACCP evidence-based clinical practice guidelines. Chest. 2006; 129(1 Suppl):138S-146S. Where to find resources (intermountainphysician.org) LOWER RESPIRATORY WORKGROUP GermWatch: Patient and Provider Education Materials: Adult Acute Bronchitis • Nathan Dean, MD • Matt Mitchell, PharmD version is • Tony Wallin, MD • Jan Orton, RN available from the home page of Available at intermountainphysician.org/ Flash Card: Also available • Wayne Cannon, MD • David Pombo, MD intermountainphysician.org. Patient/public clinicalprograms (click Primary Care on on the Bronchitis topic page. • Sarah Daly, DO • Lorrie Roemer, RN version available from germwatch.org. the left, then Topics, then Bronchitis). • Richard Ensign, PharmD • Jason Spaulding, MD ADULT BEST PRACTICE FLASH CARD Bronchitis, Acute • David Hale, PharmD, MHA • Tracy Vayo, MA Reference To order copies of DIAGNOSIS Link • Sharon Hamilton, RN materials, go to Acute Cough Symptoms Possible yes Chest (+) Pneumonia pneumonia? x-ray CPM i-printstore.com. no (-) This CPM may need to be adapted to meet the individual needs of a specific Asthma yes Possible asthma? CPM no Antibiotics ONLY if severe Possible rhinosinusitis? yes patient. It should not replace clinical judgment. As always, the Lower or persistent symptoms no

• Symptom relief, education Possible influenza? yes • Consider flu test, antiviral Respiratory Infection Team welcomes comments or recommendations for Check if within 48 hrs of onset Germ no Watch • Test & treat ONLY if sx with known exposure or Possible pertussis? yes local outbreak improvement. Contact Dr. Anthony Wallin at 801-269-2441 or e-mail no • Get vaccination up to date

Possible exacerbation yes COPD of chronic bronchitis? CPM [email protected]. no

Treat acute bronchitis (chest cold)

©2013 Intermountain Healthcare. CPM014fca - 12/13 Reference: Acute Cough (Bronchitis) (CPM014) Not intended to replace physician judgment with respect to individual variations and needs. ©2008-2013 Intermountain Healthcare. All rights reserved. Patient and Provider Publications 801-442-2963 CPM014 - 12/13