Cap Guidelines For Use

University of Maryland Medical Center

Summary of Community Acquired Pneumonia (CAP) Guidelines Recommendation I: Risk Stratification for Patients with Community Acquired Pneumonia. The goal is to define inclusion and exclusion criteria for the diagnosis of CAP and stratify patients into risk for mortality based upon a score using age, clinical indicators, comorbid conditions and laboratory data. Scores classify patients into five categories, with patients scoring I & II considered low risk for mortality and candidates for home management, patients scoring IV-V considered higher risk for mortality and candidates for hospitalization, while patients scoring III may require hospitalization depending upon home management and monitoring capabilities. Recommendation II: Diagnostic Studies and Follow-up Indicated in the Management of CAP. The goal is to identify appropriate diagnostic testing and post-discharge follow-up for the diagnosis and management of CAP. Recommendation III: Empiric Antibiotic Selection for CAP and Conversion from IV to PO. The goal is to identify appropriate antibiotic(s) choices for the management of less severe (admitted to general medical unit) and more severe (admitted to ICU) CAP patients. Recommends refining and focusing the antibiotic choice once the culture and sensitivity report is available and switching from IV to PO when patient meets specific criteria set by the recommendation. Recommendation IV: Treatments “Not Routinely” Indicated in the Management of CAP. The goal is to discourage the inappropriate use of chest physiotherapy and aerosolized medications in the routine management of Community Acquired Pneumonia where they do not have established efficacy. The recommendation also identifies those areas where chest physiotherapy and aerosolized medications have a role. Recommendation V: Discharge Criteria for Adult Patients with CAP. The goal is to identify when patients meet low risk criteria and can be safely discharged to a lower level of care based upon clinical status and absence of unstable comorbid conditions.

University of Maryland Medical Center

Guidelines: Inclusion Criteria and Risk Stratification for Patients with Community Acquired Pneumonia

DATE

IMPRINT WITH PATIENT PLATE

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Disclaimers for Pathways and Guidelines: Clinical Pathways and Guidelines are developed by a multidisciplinary team. The are guidelines for care. They are not compulsory or mandatory plans of treatment or standards of care. When considering individual patient needs, alternative independent clinical assessments and judgements may be necessary.

Grades of Evidence: A = Good evidence to support recommendation B = Moderate evidence to support the recommendation C = Poor evidence to support the recommendation D = Evidence against the recommendation

I = At least 1 randomized, controlled trial supports recommendation II = At least 1 trial without randomization supports recommendation III = “Expert opinion”

Recommendation I: Inclusion Criteria, Risk Stratification and Clinical Pathway Eligibility for Patients with Community Acquired Pneumonia Best Grade of Evidence: A-I Population: Patients > 18 years of age presenting with suspicion of Community Acquired Pneumonia (CAP). Purpose: To appropriately identify patients with CAP for admission to an inpatient bed based on a scoring system that assesses pneumonia severity. Patients admitted to an inpatient bed will be placed on the CAP pathway. Inclusion Criteria: Presence of an infiltrate on chest radiograph and at least one of the major or two of the minor criteria as follows: Major criteria: Cough, sputum production, presence or history of fever Minor criteria: Dyspnea, pleuritic chest pain, pulmonary consolidation on physical exam, or white blood cell count >12,000. Exclusion Criteria: Patients who: 1. < 18 years of age 2. requires mechanical ventilation 3. history of aspiration pneumonia 4. history of post-obstructive pneumonia 5. history of HIV or suspected HIV infection 6. are immunosuppressed (chronic use of systemic steroids or other immunosuppressive agents, active treatment of cancer, history of organ transplant) 7. have active tuberculosis 8. have cystic fibrosis 9. have been hospitalized within the past 7 days 10. have been transferred from another acute facility 11. nursing home patients (included when scoring risk stratification but not included on pathway.)

Disclaimers for Pathways and Guidelines: Clinical Pathways and Guidelines are developed by a multidisciplinary team. The are guidelines for care. They are not compulsory or mandatory plans of treatment or standards of care. When considering individual patient needs, alternative independent clinical assessments and judgements may be necessary.

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PNEUMONIA SEVERITY SCORE TOOL: Assign a score using the “Pneumonia Severity Scoring Tool” (page 3,4). A total point score for a given patient is obtained by adding the patient’s age in years (age minus 10 for women) plus the points for each applicable characteristic. The sum of the points places each patient into the following risk class: 1. Patients meeting inclusion criteria and are less than 50 years of age with no co-existing illnesses or abnormal physical findings, assign Risk Class I. 2. Patients meeting inclusion criteria with a total score of less than 70 points, assign Risk Class II. 3. Patients meeting inclusion and have a total score greater than 71, assign Risk Class III – V. 4. Consider home management for Risk Class I - III unless social/management issues preclude safe home discharge. Risk Class I – lowest II - < 70 points III – 71-90 points IV – 91-130 points V - > 130 points



Risk of 30 day mortality (%) 0.1 0.6 0.9 9.3 27.0

Recommended Site of Care outpatient outpatient outpatient or brief inpatient inpatient inpatient

GENERALLY CLASS I-II ARE MANAGED AT HOME AND CLASS III ARE POTENTIAL CANDIDATES FOR OUTPATIENT TREATMENT OR BRIEF INPATIENT OBSERVATIONS. PATIENTS IN CLASSES IV-V SHOULD BE HOSPITALIZED.

RISK CLASS I: Patients should meet the following criteria: ♦

< 50 years of age

♦

No history of: 1. neoplastic disease 2. congestive heart failure 3. cerebrovascular disease 4. renal disease 5. liver disease

♦

None of the following abnormalities present on physical exam: 1. Altered mental status 2. Pulse > 125/min 3. Respiratory Rate > 30/min 4. Systolic blood pressure < 90 mmHg 5. Temperature < 95 F or > 104 F

Disclaimers for Pathways and Guidelines: Clinical Pathways and Guidelines are developed by a multidisciplinary team. The are guidelines for care. They are not compulsory or mandatory plans of treatment or standards of care. When considering individual patient needs, alternative independent clinical assessments and judgements may be necessary.

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RISK CLASS II-V: Characteristic

Points Assigned

Demographic factor Age Men……………………………………………………………………………………..……….age in yrs Women…………………………………………………………………………………………..age in yrs – 10 Nursing Home Resident (patients included in severity scoring tool but not included on clinical pathway)

+ 10

Co-existing illness: Neoplastic disease…….…any cancer except basal or squamous cell cancer of the skin that was active at the time of presentation or diagnosed within one year of presentation. Liver disease…………..…clinical or histologic diagnosis of cirrhosis or another of chronic liver disease, such as chronic active hepatitis. Congestive……………....systolic or diastolic ventricular dysfunction documented Heart Failure by history, physical exam, and chest radiograph, echocardiogram, multiple gated acquisition scan, or left ventriculogram. Cerebral …………….…...clinical diagnosis of stroke or transient ischemic attack Vascular Disease or stroke documented by MRI or CT. Renal Disease…………....history of chronic renal disease or abnormal BUN and SCr concentrations documented in the medical record. Physical Examination Findings: Altered mental status……disorientation with respect to person, place or time that is not known to be chronic, stupor or coma. Pulse > 125/min Respiratory Rate > 30/min Systolic blood pressure < 90 mmHg Temperature < 95 degrees F or > 104 F Laboratory and Radiographic Findings: Arterial pH <7.35 BUN > 30 mg/dl Sodium < 130 mmol / liter Glucose > 250 mg/dl Hematocrit < 30% Partial pressure of arterial oxygen <60 mmHg [ O2 sat < 90%] Pleural effusion

+ 30 + 20 + 10

+ 10 + 10

+ 20 + 10 + 20 + 20 + 15 + 30 + 20 + 20 + 10 + 10 + 10 + 10

Total Points/Assigned Class ______________ < 70 points

Class II

(Consider Home Management)

71 – 90 points

Class III

(Potential Home Management)

91 – 130 points Class IV (Hospital Admission Recommended) >130 points Class V (Hospital Admission Recommended)

Disclaimers for Pathways and Guidelines: Clinical Pathways and Guidelines are developed by a multidisciplinary team. The are guidelines for care. They are not compulsory or mandatory plans of treatment or standards of care. When considering individual patient needs, alternative independent clinical assessments and judgements may be necessary.

Start Date:

Patient’s Allergies:

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IMPRINT PATIENT NAME

Pneumonia Severity Scoring Tool For Community Acquired Pneumonia If patient < 50 y.o. & has no coexisitng illnesses (A) or abnormal physical findings (B)

Assign Class I Consider Home Management Assign Points: Men = age (years): ______ Women = age (years) – 10: _____ Total Points:_______

No Age in years?

Is patient a nursing home resident?

Does patient have a specific co-existing illness?

Does patient have any abnormal physical findings?

Does patient have any abnormal laboratory or radiographic findings?

♦

Yes

Yes

Yes

Yes

< 70 Points: Assign Class II (Consider Home Management) ♦ 71-90 Points: Assign Class III (Potential Candidates for Home Management) ♦ 91-130 Points: Assign Class IV (Hospital Admission Recommended) ♦ >130 Points: Assign Class V (Hospital Admission Recommended)

Assign Points: +10 Assign Points: Neoplastic Disease: +30 Liver Disease: +20 Cerebrovascular Disease: +10 Congestive Heart Failure: +10 Renal Disease: +10 Total Points: ________ Assign Points: Altered Mental Status: +20 Respiratory Rate > 30/min: +20 Systolic BP < 90 mmHg: +20 Temp < 95 ° F or >104 ° F: +15 Pulse > 125/min: +15 Total Points: _________ Assign Points: Arterial pH < 7.35: +30 BUN > 30mg/dl: +20 Sodium < 130 mmol/liter: +20 Glucose > 250mg/dl: +10 PO 2 < 60 mmHg or 0 2 sat 90%:+10 Hematocrit < 30%: +10 Pleural effusion: +10 Total Points: _________

Total Assigned Points =

Assigned Points:

Disclaimers for Pathways and Guidelines: Clinical Pathways and Guidelines are developed by a multidisciplinary team. The are guidelines for care. They are not compulsory or mandatory plans of treatment or standards of care. When considering individual patient needs, alternative independent clinical assessments and judgements may be necessary.

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Expected Benefits: 1. Appropriate initial deposition according to risk classification 2. Improved quality of care References: 1. Niederman MS, Bass JB, Campbell DG, et al. Guidelines for the initial management of adults with communityacquired pneumonia: diagnosis, assessment of severity, and initial antibiotic therapy. American Thoracic Society 1993; 148:1418-26. (Grade B). 2. Weingarten SR, Riedinger MS, Hobson P, et al. Evaluation of a pneumonia practice guideline in an interventional trial. Am J Respir Crit Care Med 1996;153:1110-5. (Grade B). 3. Weingarten SR, Reidinger MS, Varis G. Identification of low-risk hospitalized patients with pneumonia; implications for early conversion to oral antibiotic therapy. Chest 1994;105:1109-15. (Grade C). 4. Fine MJ, Auble TE, Yealy DM. A prediction rule to identify low-risk patients with community-acquired pneumonia. NEJM 1997;336:243-50. Recommendation II: Diagnostic Studies and Follow-up Indicated in the Management of CAP Best Grade of Evidence: A-I Population: All adult patients admitted with diagnosis of CAP. Purpose: To identify appropriate diagnostic testing for inpatient management of CAP. Inclusion/Exclusion Criteria: See Recommendation I STANDARD DIAGNOSTIC WORK-UP A. INITIAL WORK-UP 1. Consider sputum gram stain and culture and sensitivity prior to initiation of antibiotics (obtain within 2 h of arrival) (B-II) a. DO NOT WITHHOLD ANTIBIOTICS PENDING SPUTUM COLLECTION/REPORT. ADMINISTER ANTIBIOTICS WITHIN 4 HOURS. b. Cancel sputum specimen if collected > 8 hours after start of antibiotics Re-evaluate the antibiotic choice when: ♦ Culture and sensitivity report is available (usually within 24 – 36 hours) 2. Chest Xray (CXR): PA and Lateral (A-II) 3. CBC, Chem-7 (Electrolytes, BUN, SCr, Glucose) 4. Blood Cultures: 2 sets (obtain at different sites prior to antibiotic administration) (A-I) 5. Consider ABG in patients Class II or greater (see Recommendation I) 6. Lateral decubitus film if evidence of pleural fluid on physical examination. B.

a

FOLLOW-UP 1. No routine follow-up of sputum. 2. If room air O2 saturation < 92% consider O2 administration and follow-up oximetry within 8 hours when indicated. 3. No routine follow-up of CXR, unless patient is not responding appropriately to treatment. 4. If worsening dyspnea, falling O2 saturation, or failure to improve, obtain the following: a. Repeat CXR and CBC. b. Consider Pulmonary and/or Infectious Disease consult(s). 5. Post-Discharge follow-up: a. Appointment for follow-up with MD in 7-10 days. b. Documentation of plan for pneumovax if patients > 65 years of age and influenza vaccines if patients > 50 years of age and/or has renal, cardiovascular or pulmonary co-morbidities.

Cost implications: Reduction in cost due to efficiency in management and decrease in LOS.

Disclaimers for Pathways and Guidelines: Clinical Pathways and Guidelines are developed by a multidisciplinary team. The are guidelines for care. They are not compulsory or mandatory plans of treatment or standards of care. When considering individual patient needs, alternative independent clinical assessments and judgements may be necessary.

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References: 1. Fine M, et al. Prognosis of patients hospitalized with community acquired pneumonia. The American Journal of Medicine 1990;88:5-8. 2. Fine MJ, Auble TE, Yealy DM. A prediction rule to identify low-risk patients with community-acquired pneumonia. NEJM 1997;336:243-50. 3. Niederman MS, Bass JB, Campbell DG, et al. Guidelines for the initial management of adults with community- acquired pneumonia: diagnosis, assessment of severity, and initial antibiotic therapy. American Thoracic Society 1993; 148:141826. 4. Bartlett JG, Dowell SF, Mandell LA, et al. Practice guidelines for the management of community-acquired pneumonia in adults. CID 2000;31:347-82. 5. Marrie TJ. Community-acquired pneumonia, state-of-the-art clinical practice. CID 1994;18:501-15. 6. Jay SJ, Johanson WG, Pierce AK. The radiographic resolution of streptococcus pneumonia. NEJM 1975;93:798-801. 7. Woodhead MA, Arrowsmith J, Chamberlain W, et al. The value of routine microbial investigation in CAP. Respiratory Medicine 1991;85:313-17. Recommendation III: Empiric Antibiotic Selection for CAP and Conversion from IV to PO. Best Grade of Evidence: B II Population: All adult patients with diagnosis of CAP. Purpose: To optimize antibiotic treatment for patients admitted with CAP Inclusion/Exclusion criteria: See Recommendation I Patients admitted with community acquired pneumonia should receive empiric antibiotic therapy in the Emergency Department within 4 hours of admission if a direct admit patient. A. Empiric Antibiotic Selection: Ordered in ED when diagnosis is made. Drug Recommendations for Home Management Treatment Options: Home Therapy Drug Regimens: Macrolide OR Fluoroquinolone Preferred Antibiotics of Choice: Clarithromycin 500 mg po bid Clarithromycin XL 1000 mg po qd Azithromycin 500 mg po qd Levofloxacin 500 mg po qd Gatifloxacin 400 mg po qd Moxifloxacin 400 mg po qd Alternative Choices: Amoxicillin-clavulanate 500 mg po Q 12 hours Doxycycline 100 mg po Q 12 hours Treatment Options: Empiric Drug Regimens:

Preferred Antibiotics of Choice:

Approximate Cost Per Day* $41-59 $46-67 $74-106 $44-63 $40-57 $48-68 $40-57 $2

Drug Recommendations for Hospitalized Patients Less Severe Pneumonia More Severe Pneumonia Approximate Cost Per Day* (General Medical Floor) (ICU Patients) B-lactam + macrolide B-lactam + macrolide OR OR Fluoroquinolone B-lactam + fluoroquinolone Ceftriaxone 1 gm IV Q 24hrs Ceftriaxone 1 – 2 gms IV Q 24hrs + + Ceftriaxone + Azithromycin: $44-70 Azithromycin 500 mg IV qd Azithromycin 500 mg IV qd OR Gatifloxacin 400 mg IV qd

OR Ceftriaxone 1 - 2 gms IV Q 24hrs + Gatifloxacin 400 mg IV qd

Ceftriaxone + Gatifloxacin: $44-70 Gatifloxacin: $18

Special Considerations:

• B-lactam allergy: Gatifloxacin +/- Clindamycin • Failed outpatient B-lactam therapy: Gatifloxacin • Area of high S. pneumonia resistance: Gatifloxacin *9/2000

Disclaimers for Pathways and Guidelines: Clinical Pathways and Guidelines are developed by a multidisciplinary team. The are guidelines for care. They are not compulsory or mandatory plans of treatment or standards of care. When considering individual patient needs, alternative independent clinical assessments and judgements may be necessary.

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B. Refining Antibiotic Choice: Antibiotic regimen should be tailored to the results of the sputum culture and sensitivity report. 1. IV to PO Conversion: Consider IV to PO switch when clinically improved and able to tolerate at least a clear liquid diet. Class Name Macrolides

Fluoroquinolones Cephalosporins

Drug Name Azithromycin Clarithromycin

Regimen 500 mg po qd 250 mg po bid 500 mg po bid Clarithromycin XL 1000 mg po qd Gatifloxacin 400 mg po qd Levofloxacin 500 mg po qd Cefpodoxime 200 mg po bid

Cost Per Day UMMC Cost of Therapy* $10.60 $74-106 $5.90 $41-59 $5.90 $41-59 $6.66 $46-67 $5.72 $40-57 $6.32 $44-63 $6.94 $49-69

*Based on a 7 to 10 day treatment course (9/2000) References: 1. Bartlett JG, Dowell SF, Mandell LA, et al. Practice guidelines for the management of community acquired pneumonia in adults. CID 2000;31:347-82. 2. Niederman MS, Bass JB, Campbell GD et al. Guidelines for the initial empiric therapy of community acquired pneumonia:proceedings of an American Thoracic Society Consensus Conference. Am Rev Resp Dis 1993;148-26. 3. The British Thoracic Society. Guidelines for the management of community acquired pneumonia in adults admitted to the hospital. Br J Hosp Med 1993;49:346-50. 4. Mandell LA, Niederman M. The Canadian Community Acquied Pneumonia Consensus Conference Group. Antibiotic treatment of community acquired pneumonia in adults: a conference report. Can J Infect Disease 1993;16:741-9. 5. Edelstein PH. Legionnaires’ disease. Clin Infect Dis 1993;16:741-9. Recommendation IV: Treatments “Not Routinely” Indicated in the Management of Community Acquired Pneumonia Best Grade of Evidence: B Applicable to Population: All adult patients admitted with CAP. Purpose: To promote appropriate use of aerosolized medications and chest physiotherapy treatments, while reducing inappropriate use in the management of CAP. Recommendations: A. Chest Physiotherapy: Clinical indications for chest physiotherapy include only: 1. Atelectasis that is segmental or greater. 2. Bronchiectasis. 3. Cystic fibrosis. Chest physiotherapy is not indicated in the following settings (unless associated with above). 1. Simple pneumonia. 2. Pleural effusion. 3. Asthma. 4. Uncomplicated COPD.

Disclaimers for Pathways and Guidelines: Clinical Pathways and Guidelines are developed by a multidisciplinary team. The are guidelines for care. They are not compulsory or mandatory plans of treatment or standards of care. When considering individual patient needs, alternative independent clinical assessments and judgements may be necessary.

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B. Aerosolized Medications: Clinical Indications for aeroosolized medications include only: 1. Asthma 2. COPD 3. Cystic Fibrosis 4. Bronchiectasis 5. Reactive airway disease • In general, aerosolized medications should be delivered via Metered Dose Inhaler (MDI) (See respiratory guideline for aerosol medications). Cost Implications: Cost of treatments and medications. References: Chest Physiotherapy: 1. Alexander E, et al. Clinical strategies to reduce utilization of chest physiotherapy without compromising patient care. Chest 1990;110:430-32. (Grade A) 2. Britton S, et al. Chest physiotherapy in primary pneumonia. British Medical Journal 1985;290:1703-04. (Grade A) 3. Kirilloff L, et al. Does chest physical therapy work? Chest 1985;88:436-444. (Grade S) 4. Anonymous. Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease (COPD) and asthma. American Review of Respiratory Disease 1987;136:225-44. Aerosolized Medications: 1. Peruzzi W, et al. Bronchial hygiene therapy. Critical Care Clinics 1995;11:82-96. 2. Hess D, et al. Aerosol therapy. Respiratory Care Clinics of North America 1995;235-63. 3. Bowton D, et al. Substitution of metered-dose inhalers for hand-held nebulizers. Chest 1992;101:305-8. 4. Kacmarek R, et al. The interface between patient and aerosol generator. Respiratory Care 1991;36:952-76. 5. Tenholder M, et al. A model for conversion from small volume nebulizer to metered dose inhaler aerosol therapy. Chest 1992; 101:634-37. Guideline V: Discharge Criteria for Adult Patients Admitted with Community Acquired Pneumonia. Best Grade of Evidence: C Population: All adult patients admitted with diagnosis of CAP. Purpose: To accurately classify patients at low risk for discharge and safely reduce LOS. Inclusion Criteria: Adult patients admitted with CAP. Recommendations: Consider patient at low risk for post discharge complications when most of the following criteria are met: 1. No active co-morbid conditions or complications requiring continued hospitalization. 2. Criteria met for conversion of IV to PO. 3. No clinical evidence of dehydration. 4. Mental status at baseline. 5. Stable or decreasing supplemental oxygen requirements. Cost Implications: Increased efficiency of inpatient resources. References: 1. Weingarten SR, Riedinger MS, et al. Identification of low-risk hospitalized patients with pneumonia, implications for early conversion to oral antibiotic therapy. Chest 1994;105:1109-15. (C) 2. Fine MJ, et al. Pneumonia in the elderly: the hospital admission and discharge decision. Seminars in Respiratory 1990;5:303-13. (E) 3. Fine MJ, et al. A predication rule to idnetify low-risk patients with community acquired pneumonia. NEJM 1997;336:243-50. (C) 4. Rhew DC, et al. The clincal benefit of in-hospital observation in “low-risk” pneumonia patients after conversion from parenteral to oral antibiotic therapy1997. (C)

University of Maryland Medical Center

5.

Haim E, Fine MF, et al. Time to clinical stability in patients hospitalized with community-acquired pneumonia, implications for practice guidelines. JAMA 1998;279:1452-57.

START DATE

University of Maryland Medical Center Treatment of Community-Acquired Pneumonia

IMPRINT WITH PATIENT’S PLATE BEFORE USING

Patient Admitted to Emergency Department

Pneumonia Diagnosis by Radiograph and Symptoms

< 70 points Risk Class I

Pneumonia Severity Index Scoring Standard Diagnosis Work-Up

Consider Home Management

> 90 points Risk Class IV -V

< 90 points Risk Class II - III

Patient Potential Candidate for Home

NO Patient Admitted to Hospital Sputum, culture and sensitivity, Blood Cultures

YES Cultures NOT needed for outpatient management

Medicine Floor B-lactam + macrolide Or Fluoroquinolone

ICU B-lactam + macrolide Or B-lactam + quinolone

First Dose Within 4 h of Presentation to Emergency Department Macrolide Or Fluoroquinolone Orally for 7-10 days

• •

Repeat CXR in 6 weeks Consider pneumovax and influenza vaccines if deemed appropriate

Criteria for Switching to Oral Therapy: Able to Eat and Drink and Clinical Improvement

Criteria for Discharge: Criteria as Listed Above for Switch to Oral Therapy Stable Comorbid Illness Normal Oxygenation (Oxygen Saturation>90% with room air) 10/200010/2000 Discharge Outpatient Antibiotic Treatment for a Total of 7-10 days

Community Acquired Pneumonia Critical Elements (LOS Goal: 3 days)

Inclusion Criteria: Adult patients with the presence of infiltrate on chest xray and at least one of the major or two of the minor criteria as follows: Major: Cough, sputum production or presence or history of fever Minor: Dyspnea, pleuritic chest pain, pulmonary consolidation on examination or WBC >12,000. Exclusion Criteria: Patients who have: • Patients that are transferred from another facility (nursing home/acute care) or have been hospitalized within past 7 days • Immunosuppressed, history of HIV or suspected HIV • Active TB, aspiration pneumonia, post-obstruction pneumonia or requires mechanical ventilation Emergency Department: • Risk stratification scored • Blood cultures (only if patient is admitted) obtained before antibiotics given • Antibiotic choice per guideline; given within 4 hours of arrival at hospital Floor: • IV antibiotics switched to po when patient is tolerating at least a clear liquid diet and shows clinical improvement • If patient is showing clinical improvement, follow-up chest xray is not indicated before six weeks • Chest physical therapy not indicated in management of pneumonia Discharge Plan From Floor: • Patient lists avoidable risk factors and preventable measures for upper respiratory infections • Documentation that pneumovax and influenza vaccines have been addressed • Has plan for follow-up appointment