Each issue of the CoramClick provides an in-depth focus on timely and practical solutions. In this issue of the Click, we are focusing on Pancreatitis. Full, printable issues of the Click are available in the CoramClick archive for easy reference!

	Pancreatitis Pancreatitis is a challenging disease that requires many clinical interventions across the continuum of care. Acute pancreatitis is a growing diagnosis in the U.S., appearing in 70-80 of every 100,000 individuals.		Bug of the Month: Staphylococcus Aureus Staphylococcus aureus is one of the most prevalent bacterium in the healthcare setting and is the most common pathogen cultured from nosocomial infections.
	Discharge Planning Strategies Optimally, discharge planning begins at the time of admission. However, in reality, the hospital discharge planner or physician may not formulate a discharge plan until the patient’s clinical condition stabilizes.		Do You Know? According to the Journal of the American Medical Association in 2007, how many people died during a hospital stay related to serious MRSA infection?    a) 17,500   b) 18,650   c) 19,875
	Common ICD-9 Codes A list of certain ICD-9 codes associated with pancreatitis. Please note, this list is not all-inclusive.		Resource Center Featuring: Pancreas.org, the CDC and Medline Plus, a service of the U.S. National Library of Medicine and the NIH.
	Subscribe to the CoramClick. Please include your email, first and last name, company, city and state.

Pancreatitis
Care Management’s Impact on Healthcare Utilization

Pancreatitis is a challenging disease requiring many clinical interventions across the continuum of care. Acute pancreatitis is a growing diagnosis in the United States, appearing in 70–80 of every 100,000 individuals. Chronic pancreatitis is seen in a range of 3–10 of every 100,000 individuals. Of the patients suffering with acute pancreatitis, 80 percent will be admitted to the hospital with mild disease. The other 20 percent are admitted with severe disease. In general, patients that suffer from pancreatitis typically utilize multiple interventions and therapies for treatment and control of their disease. The management of this population often generates relatively high costs associated with hospitalizations. A comprehensive, consistent management approach is needed which encompasses inpatient acute care as well as support in the home care setting.

Nutrition Management
The pancreas plays a key role in the digestive system. Inflammation of the pancreas and/or damage to the pancreas results in a high risk of nutritional compromise for the patient. Often, malnutrition is a complication of pancreatitis. Malnutrition results from hypermetabolism, decreased oral intake due to a need for bowel rest and pain upon intake and malabsorption due to a deficiency of pancreatic enzymes. Nutritional management is essential to the management of pancreatitis. Pancreatic, or bowel rest, is necessary to minimize enzyme secretion and to promote resolution of inflammation. When oral intake is prohibited for five to seven days or more, enteral (“tube feeding”) or parenteral (“TPN”, provision of all necessary nutrients via an intravenous feeding) nutrition support should be considered and initiated to maintain nutritional status. An enteral feeding tube must be placed lower in the small intestine and into the jejunum so that pancreatic enzymatic secretion is not required. This is established by a jejunal tube feeding placed as a percutaneous endoscopic gastrojejunostomy or through a direct jejunostomy. Parenteral nutrition is used for patients who cannot tolerate an oral diet or jejunal tube feeding, or for those who cannot have a jejunal tube placed.

Pain and Symptom Management
Pain exacerbations associated with pancreatitis have been identified as a major cause of increased hospital lengths of stay as well as re-hospitalizations. An estimated 95 percent of chronic pancreatitic patients suffer from intractable abdominal pain. Aggressive and appropriate pain and symptom management can be extended to home care when specialized, standard monitoring and management is made available. This treatment strategy supports timely discharges for pancreatic patients, allows for transition to less invasive therapies as tolerated, and supports proper symptom management without compromising the overall goal of improved function and quality of life.

Anti-Infective Management
Infection management is a key issue when analyzing morbidity and mortality in the pancreatitis patient population. Infections can include a number of clinical events relating to the pancreas such as necrosis, abscess and pseudocysts. Patients with acute pancreatitis develop bacterial infections at a rate of 30 percent with the highest percentage and occurrence in patients with pancreatic necrosis. Pancreatic necrosis alone is linked to a mortality rate of 15-20 percent. Current literature supports clinical interventions consisting of prophylaxis of infections, identified through proper laboratory and patient monitoring, throughout the course of the disease. Initiation of intravenous antibiotic therapy or completion of hospital-administered doses, whether it is with an identified infection or prophylactic, can occur safely in the home care setting. This leads to hospital admission avoidance and reduced hospital length of stay when clinically appropriate.

Discharge Planning Strategies

Optimally, discharge planning begins at the time of admission. However, in reality, the hospital discharge planner or physician may not formulate a discharge plan until the patient’s clinical condition stabilizes. Furthermore, the goals for discharge may include a transition to oral intake for nutrition, pain and symptom control and/or anti-infective management that could otherwise be administered at home. An important objective of the utilization management review is determining the earliest point in the hospitalization when it would be appropriate to begin discussing the patient’s discharge planning needs. Generally this occurs when the patient’s clinical condition begins to stabilize and the intensity of services has decreased. The following questions can help trigger a discharge planning assessment by the reviewer.

• Are the vital signs stabilizing?
• Are the labs improving (e.g., amylase and lipase)?
• Are the patient’s symptoms improving and/or controlled (e.g. nausea, vomiting)?
• Is nutrition support established (e.g., PN, enteral feedings, oral route re-established)?
• Could the nutrition support be initiated in the home to avoid hospitalization or facilitate discharge?
• Is the patient’s pain controlled with the current therapeutic regimen?
• Is the patient tolerating the infusion therapies?
• If the patient were clinically stable could these therapies be managed at home?

Avoiding Re-hospitalizations
Pain and symptom management can be primary reasons pancreatitic patients seek emergency treatment and may result in re-hospitalization. Patients discharged on home infusion therapy can have therapies managed to address these symptoms when medically appropriate. It is not uncommon to have medications adjusted, added or discontinued during the course of home care with proper clinical management. However, physicians caring for pancreatitic patients with no home infusion needs may not be aware that infusion therapy can be an option in some cases for symptom flare ups. Outpatient case management by the payor can be a successful proactive strategy to avoid re-hospitalizations which lead to cost savings associated with pancreatitis patients.

Components of an internal plan to achieve cost savings could include:

• Referral of high-risk pancreatitic patients to for case management follow-up
• Chronic pancreatitis
• Patients hospitalized two or more times for acute pancreatitis in a 12-month period
• Patients diagnosed with necrotizing or hemorrhagic pancreatitis
• Patients with a current or previous complicated hospital course resulting in more than two weeks hospitalization
• Follow-up call to the patient and family assessing the patient’s subjective symptoms after discharge and plans for physician follow-up.
• Follow-up phone call to the patient’s physician providing them with a clinical update from the details of the conversation with their patient. This is an excellent opportunity to educate the physician about the option for home infusion therapy for symptom flare-ups. Providing the physician and/or office nurse with the patient’s infusion benefit and preferred provider will help facilitate the referral process.

These strategies aid in the overall goal to facilitate timely discharges and avoid unnecessary re-hospitalizations and emergency room visits for this complicated patient population.

Common ICD-9 Codes

Below is a list of certain ICD-9 codes associated with pancreatitis. Please note that this list is not all-inclusive and ICD-9 codes are updated on a regular basis. Always make sure that you are using the current and correct codes.

Bug of the Month: Staphylococcus aureus

Staphylococcus aureus bacterium. The bacterium is one of the most common causes of skin infections. Image courtesy of the CDC/Janice Carr.

Staphylococcus aureus is one of the most prevalent bacterium in our environment. In the healthcare setting, it is the most common pathogen cultured from nosocomial infections and is one of the most prevalent bacterium. Staph. aureus is found on the skin and in the nares of up to 30 percent of the healthy population. Such individuals are thus colonized. The bacterium is one of the most common causes of skin infections. Most are minor and can be treated for example, with an incision and drainage, and will not require antibiotics. However, Staph can also cause serious infections, such as surgical wounds, bloodstream infections and pneumonia.

Methicillin-resistant
Staphylococcus aureus (MRSA)
Methicillin-resistant Staphylococcus aureus (MRSA) is resistant to methicillin and other more common antibiotics such as oxacillin, penicillin and amoxicillin. MRSA is endemic in hospital settings, with a sobering increase in incidence from 2 percent of the total number of Staph. aureus infections in 1974, to 22 percent in 1995, and 63 percent by 2004. MRSA remains the most common cause of nosocomial or healthcare-acquired infections, at significant economic and clinical cost burdens.

MRSA infections are currently categorized as healthcare-or community-associated. Healthcare-associated infections include those with hospital or community onset. Community-associated infections also have their onset in the community, but are without the risk factors identified for community-onset (see Table 1).

Approximately 85 percent of MRSA infections are healthcare-associated, often developing into invasive disease with multiple potential clinical syndromes, many of which may be recurrent and/or fatal (see Table 2).

Community-acquired MRSA (CA-MRSA)
Significantly, MRSA has recently emerged in the community, now accounting for about 14 percent of all MRSA infections. CA-MRSA is one of the most common causes of skin infections. Typically, these infections appear as small pustules or boils that are often red, swollen, and painful or have pus associated with them. While rare in healthy people, more serious CA-MRSA infections can occur, such as pneumonia, bloodstream infections and bone infections.

CA-MRSA infections are usually spread by contact with another person’s skin infection or personal items they used, like towels, bandages or razors that touched their infected skin. Crowding, frequent skin-to-skin contact, cuts and abrasions, contaminated items or surfaces, and lack of cleanliness, for example, have been associated with increased incidence of CA-MRSA. Some potentially risky settings might include schools, dormitories, military barracks, prisons, locker rooms and daycare centers.

Treatment
The preferred treatment for MRSA nasal colonization is mupirocin ointment applied to the nares. Vancomycin is the drug of choice for serious MRSA-related infections, although there is also evidence of an emerging and troubling trend for vancomycin-resistant Staphylococcus aureus (VRSA).

Risk Factors for Developing Infection

• Advanced age
• Prolonged hospital length of stay
• Compromised immunity
• Critically ill patient in ICUs
• Exposure to broad-spectrum antibiotics
• Presence of surgical wound or decubitus ulcer
• Invasive indwelling devices (e.g., IV catheters, urinary catheters, G-tubes)
• Previous hospitalization
• Resident in a long-term care facility
• Physical proximity to patients colonized or infected with MRSA

Do You Know?

According to the Journal of the American Medical Association in 2007, how many people died during a hospital stay related to serious MRSA infection?

1. a) 17,500
2. b) 18,650
3. c) 19,875

Answer: b) 18,650

Resource Center

An excellent online resource for pancreatitis is www.pancreas.org. The site features separate areas for patients, physicians and research. There are a number of downloadable resources ranging from question and answer sessions with physicians to guidelines and consensus statements.

The Centers for Disease Control and Prevention (CDC) website, www.cdc.gov, is a great source for information pertaining to MRSA. The site contains a general overview, prevention and even data and statistics. There is even a podcast that is available for download.

Medline Plus is a service of the U.S. National Library of Medicine and the National Institutes of Health and contains useful information about MRSA. There are links to articles from various medical journals, links to recent research studies and a latest news section. Visit Medline Plus to learn more.

Bibliography

• Banks, PA. (2002). Epidemiology, natural history, and predictors of disease outcome in acute and chronic pancreatitis. Gastrointestinal Endoscopy, 56(6).
• Khokhar, AS, Seidner, DL. (2004). The pathophysiology of pancreatitis. Nutrition in Clinical Practice, 19(1): 5-15.
  Guidelines for the Use of Parenteral and Enteral Nutrition in Adult and Pediatric Patients. ASPEN Board of Directors, Journal of Parenteral and Enteral Nutrition, 2002; 26(1) S: 68SA-70SA.
• Salim AS. (1997).Perspectives in pancreatic pain. HPB Surgery, 10: 269-277.
• Proctor, D. (2003). Critical issues in digestive diseases. Clinics in Chest Medicine, 24(4).
• Ratschko, M, Fenner, T., Lankisch, P. (1999). The role of antibiotic prophylaxis in the treatment of acute pancreatitis. Gastrenterology Clinics, 28 (3).
• Klevins, RM, Morrison, MA, Nadle, J, Petit, S, Gershman, K., Ray, S. Harrison, LH, et al (2007). Invasive methiciliin-resistant Staphylococcus aureus infections in the United States. JAMA; 298(15), 1763-1771.