Nursing Center - Journal Article

In this month's Ask Home Healthcare Nurse, a variety of readers' questions have been answered by home care experts in the areas addressed.

Measuring Blood Pressure Different Ways

Q: My patient has a cast on his right upper arm because of a fractured humerus and a peripherally inserted central catheter (PICC) in his left upper arm, which is used to administer intravenous antibiotic therapy. Because of the patient's circumstances, it is not appropriate to use a blood pressure (BP) cuff on his upper arm. Are there any other options for monitoring his BP?

A: In unusual circumstances such as this, BP can be checked using the forearm and feeling (or auscultation) for the presence of the radial pulse, giving you a systolic BP reading. Diastolic readings may be falsely high when using the forearm method. In general, the accuracy of forearm BP is not well validated (Billington et al., 2002;Perloff et al., 1993). However, for most patients it is certainly better to monitor BP than to ignore this important assessment parameter. Make sure that the patient's plan of care clearly identifies the method for BP assessment and share the method used when reporting unusual BP results to the physician.

Note that a BP taken in the forearm should not be used as a routine practice with the obese patient. For patients with an arm circumference that exceeds 33 to 34 cm (approximately 13 inches), a large BP cuff should be made available by the home care agency and used appropriately. An overestimation of BP is seen when standard BP cuffs are used with the obese patient (Graves, 2001).

Hypertension is the most common primary diagnosis in the United States, and high BP is an important causative factor in the development of cardiac, renal, and cerebrovascular disease (National Institutes of Health, 2003). As home care nurses, we have great opportunity to monitor BP and provide patient and family education about the deleterious effects of hypertension and strategies to reduce BP.

REFERENCES

Billington, C. J., Epstein, L. H., Goodwin, N. J., Liebel, R. L., Pi-Sunyer, F. X,. & Pories, W., et al. (2002). Medical care for obese patients: Advice for health care professionals. American Family Physician, 65 (1), 81-88. [Context Link]

Graves, J. W. (2001). Prevalence of blood pressure cuff sizes in a referral practice of 430 consecutive adult hypertensives. Blood Pressure Monitoring, 6 (1), 17-20. [Context Link]

National Institutes of Health. (2003). NIH report no. 03-5233. The seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. Retrieved January 3, 2004 from http://www.nhlbi.nhi.gov/guidelines/hypertension/jnc7full.pdf. [Context Link]

Perloff, D., Grim, C., Flack, J., Frohlich, E., Hill, M., McDonald, D., et al. (1993). Human blood pressure determination by sphygmomanometry. Circulation, 88 (5), 2460-2470. [Context Link]

Answer by: Lisa Gorski, MS, APRN, BC, CRNI, Clinical Nurse Specialist, Covenant Home Health and Hospice, Milwaukee, WI.

Medicare and Standing Orders

Q: We recently obtained a "standing order" from our medical staff to have a WOCN (Wound Ostomy Continence Nurse) consult on all wound care cases. Does anyone know if such a "standing order" will fly with Medicare, or if we would have to write this order on each patient and have his or her own physician sign?

A: Standing orders are not allowed for home health agency patients. According to CMS, standing orders violate the intent of regulation 42 CFR 484.18 requiring physicians to establish the plan of care for an individual patient. CMS also has expressed the opinion that allowing standing orders in home health "could lead to failure to notify the physician when a patient exhibits a new problem." CMS allows for standing orders in hospitals because "the acute care environment is more controlled, with greater physician oversight, than in home health." The only exception to the prohibition on standing orders is for administration of influenza and pneumococcal vaccines.

Answer by: Mary St. Pierre, BSN, MGA, Vice President, Regulatory Affairs, National Association of Home Care, Washington, DC.

OASIS Resumption of Care and Recertification

Q: I have recently taken the role of Branch Director of a nationwide home health agency. Recently I have discussed an OASIS question with my administrator, and her answer does not match what I thought I had understood from one of the articles. (Agency policy may dictate the answer, but we can always try to change unnecessary policies.)

An example: A patient's certification is 4/5/04 to 6/3/04. He has been in the hospital for 3 weeks and returned home on 6/2/04. Does Medicare require both a resumption of care and a recertification OASIS be completed?

A: Through September 30, 2004, the instructions for handling a resumption of care (ROC) and recertification during the last 5 days of an episode are in a document published in the fall of 2000 (when PPS went into effect for home health agencies). If only one assessment is completed, it should be the ROC. If the agency determined that it was in the agency's best financial interest to request an SCIC payment adjustment for the last few days of the certification period (and our calculations have shown that would rarely be the case during the last 5 days), then both an ROC and a recertification would be required (and yes, they could both be done at the same visit).

You can find the instructions (mentioned above) for handling this type of situation at http://cms.hhs.gov/oasis/oasispps.asp, scroll down to "OASIS Considerations for Medicare PPS Patients" and click on the link to the zip file. The information you are seeking is #4.

Transmittal 61, posted January 16, 2004, includes a section on special billing situations and can be found in the Medicare Claims Processing Manual. Go to http://www.cms.hhs.gov/manuals/104_claims/clm104c10.pdf; scroll to page 89 of the document to read "Section 80: Special Billing Situations Involving OASIS Assessments." Questions related to this document must be addressed to your regional home health intermediary (RHHI).

Effective October 1, 2004, the rules for the simplified method of handling an SCIC after an inpatient facility stay during the last 5 days of an episode have changed.

The ROC assessment should be completed, and M0825 should forecast the subsequent episode. You can find the instructions (mentioned above) for handling this type of situation at http://cms.hhs.gov/oasis/oasispps.asp, scroll down to "OASIS Considerations for Medicare PPS Patients" (revised June 2004) and click on the link to the zip file. The information you are seeking is #4.

Answer found at: http://www.qtso.com/guides/hha/cat3.pdf. Accessed April 17, 2005.

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