Non-ventilator hospital-acquired pneumonia: Are you addressing the hidden issue affecting more patients at a greater cost than VAP?

This content is sponsored by Sage Products

Each year, approximately 1.7 million healthcare-associated infections occur in U.S. hospitals, affecting 5 to 10 percent of the nation's hospitalized patients annually, according to the Centers for Disease Control and Prevention. HAIs can take the form of surgical site infections, hospital-acquired pneumonia, ventilator-associated pneumonia, catheter-associated urinary tract infections and central-line associated bloodstream infections, among others.

The rising cost of healthcare, the growing concern of resistant strains of infection and quality of life issues have all prompted increased scrutiny on the acquisition of healthcare-associated infections. Organizations that monitor hospital quality, accreditation and reimbursement have implemented programs specifically designed to prevent and reduce the incidence of HAIs, therefore, HAIs have become a high-priority issue for healthcare executives.

Hospitals are now required to not only monitor and report certain HAIs, their reimbursement may be reduced or withheld if the reported rates do not improve.

In recent years, there have been decreases in many device-related infections such as VAP, due in part to the newfound focus on HAIs. While hospitals were focused on prevention, early recognition and treatment of VAP, overall hospital-acquired pneumonia rates were a less significant focus, but were increasing. A 2012 study in The New England Journal of Medicine led by Shelley Magill, MD, PhD, demonstrated that more than 60 percent of hospital-acquired pneumonia occurs in non-ventilated patients. This rate represents a significant opportunity for hospitals to improve healthcare quality, lower the cost of care and avoid reimbursement penalties.

Key opinion leaders are taking notice. "For years now, hospitals have focused heavily on ventilator-associated pneumonia," says Joyce Ryan, DNP, RN, director of the Department of Clinical Affairs for Sage Products. "It was the only term you would ever hear, and people make the assumption that the only patients on vents were getting pneumonia."

It is true that being on a ventilator dramatically increases the risk of a patient getting pneumonia. In fact, being on a ventilator is the "primary risk factor for the development of hospital-associated bacterial pneumonia," according to 2003 Guidelines for Preventing Health-Care-Associated Pneumonia from the CDC.

While it has long been known that mechanical ventilation is a significant risk factor for hospital-acquired pneumonia, several studies have recently found that the incidence of non-ventilator HAP has been largely unmonitored and under-recognized. A 2012 study published in the American Journal of Infection Control, "Clinical Attributes of Non-Ventilator-Associated Hospital-Acquired Pneumonia," called the condition "underreported and unstudied" and found the illness is "an emerging factor in prolonged hospital stays [and] patient morbidity." Researchers also noted an increased cost of around $40,000 for each case of hospital-acquired pneumonia.

Another study published in 2012 by the Pennsylvania Patient Safety Authority, "The Breadth of Hospital-Acquired Pneumonia: Nonventilated versus Ventilated Patients in Pennsylvania," made the case for increased focus on non-ventilator HAP, as researchers found the number of non-ventilator HAP cases surpassed the number of ventilator-associated infections from 2009 through 2011. Additionally, non-ventilator HAP "has the potential to become more costly than VAP [ventilator-associated pneumonia]," the researchers found.

The bottom line is "more and more patients are in the hospital with pneumonia that is not associated with a ventilator," says Trudy Robertson RN, MSN, a clinical nurse specialist with Fraser Health Neurosurgery in New Westminster, British Columbia. Changes should be made so non-ventilator HAP can be monitored as diligently as VAP.

Ms. Robertson knows the effects that non-ventilator HAP can have on patients and nurses first-hand. "As a nurse, clinically we noticed an ongoing problem in the patient population with pneumonia rates while they were in the hospital," she says. "I had lost too many patients to pneumonia. I felt as a clinical nurse specialist that we needed to do something."

That experience, paired with the literature and studies, motivated Ms. Robertson and her colleague Dulcie Carter, a registered speech language pathologist, to study the issue in order to develop interventions that could be targeted to reduce the incidence of non-ventilator HAP.

What can be done?

Since the problem of non-ventilator HAP has only been uncovered in the last few years, clinicians and researchers have just begun to develop the empirical base of evidence needed to prevent the problem. As a result of this inquiry, two main factors have emerged as effective ways to prevent this problem.

Target specific risk factors with comprehensive oral care

"There is a strong linkage between the level of oral contaminants and pneumonia," Ms. Robertson said. When there are elevated levels of bacteria in the mouth, it is more likely for bacteria to be aspirated into the patient's lungs, which can then cause pneumonia. Hospitalized patients with neurological conditions or who have difficulty swallowing are at an even higher risk.

The problem of non-ventilator HAP has only been uncovered in the last few years, and clinicians and researchers have just begun to develop the empirical base of evidence needed to prevent it.

Since there is a relationship between oral care and non-ventilator HAP, several researchers, including Ms. Robertson, looked at their own oral care processes and experimented with various methods and frequencies in order to measure the effects on pneumonia rates.

In Ms. Robertson's 2012 study, "Oral intensity: Reducing non-ventilator-associated hospital-acquired pneumonia in care-dependent, neurologically impaired patients," an enhanced oral care protocol was implemented for a group of non-intubated, care-dependent adults with a neurologic injury — in other words, a group highly susceptible to pneumonia.

First, Ms. Robertson and Ms. Carter looked into what nurses had been doing for oral care, and found training and implementation of optimal oral care was inconsistent. "Prior to initiating our research, we did not have a written, clear protocol for nurses to follow" for providing oral hygiene, Ms. Robertson says. "There were no specifics on how to adequately clean a patient's mouth with the products available," which resulted in wide variation in practice.

Next, a clear protocol was put into place. The protocol involved placing oral care kits at every patient's bedside, which included toothbrushes, swabs and hydrogen peroxide solution. The cleaning protocol was provided on nursing worksheets and a standard for documentation of oral care was developed. The protocol included an assessment of the mouth every two to four hours, tooth brushing every 12 hours, cleaning and suctioning of the oral mucosa every two to four hours and moisturizing every four hours. After the six-month study, the HAP rate of the group of patients who received enhanced oral care were compared to retrospective pneumonia rates from a group who received standard care.

The researchers found the baseline retrospective group had a 25.5 percent rate of non-ventilator HAP, while the enhanced oral care group had a 6.3 percent rate of non-ventilator HAP, which constituted a statistically significant drop in pneumonia rates.

Studies from other institutions have had similar findings. For example, a 2014 study in the Journal of Nursing Scholarship, titled "Basic Nursing Care to Prevent Nonventilator Hospital Acquired Pneumonia," that involved implementing a new oral care protocol for all adult non-ventilator patient four times per day saw the number of non-ventilator HAP cases drop by 37 percent over the study's 12-month period. The new protocol was also attributed to a reduction in mortality and had a return on investment of $1.6 million in avoided costs.

Change nurse practice

Many of the studies on the importance of implementing oral care protocols cite the importance of nurse buy-in to successfully implementing the changes. "Nurses play a vital role in preventing hospital-acquired pneumonia," the conclusion of Ms. Robertson's study in the Canadian Journal of Neuroscience Nursing states. "Foundational nursing practices, such as regular oral hygiene, are important aspects of care in preventing nosocomial infections and related costs, optimizing health and promoting quality care."

However, because of the multiple demands on the nurse's time in trying to provide optimal care for all the patient's needs, getting all nurses in a hospital or even on a unit to provide proper oral care every time can sometimes be a challenge. The following are tips to help with the process.

Tailor education efforts. When communicating a process change, like improving oral care protocols, nurse leaders should talk about the change with front-line providers in a variety of ways.

For Ms. Robertson, when she talked with nurses first about oral care, many saw oral hygiene as a comfort measure for patients and nothing more. "Center the discussion on the fact that oral care isn't just for comfort anymore — it can prevent a pneumonia event," she says.

Nearly as important as the message is the means of communicating it. Ms. Robertson found speaking with nurses during a unit huddle to be one of the most effective ways to communicate protocol change. Incorporating oral care training into nurse onboarding as well ensures that any new nurses also know the importance of oral hygiene as it relates to pneumonia.

Make it easy. When Ms. Robertson first approached nurses about changing oral care protocol, she ran into resistance from some of those on the front-line because they perceived it as adding tasks to their already full workload and were not fully aware of the benefits with regard to pneumonia prevention. In addition to education, Ms. Robertson also strove to make following the protocols as easy as possible, including putting oral hygiene kits with every patient at the bedside.

According to Dr. Ryan, oral care kits that can help prevent non-ventilator HAP should be comprehensive, including an antiseptic solution, a soft nylon-bristle toothbrush backed with a foam head to deliver sodium bicarbonate and the antiseptic solution, and finally, a suction device to remove secretions. "A comprehensive oral care system can help reduce bioburden in the mouth so if patients do aspirate, they are less likely to develop pneumonia," she says.

During training, Ms. Robertson also stressed that not only would performing oral hygiene help keep patients healthier, it could also save time in the long run. "Cleaning a mouth takes less time than caring for someone with pneumonia," she says, which she communicated with her team. "If everyone is doing mouth care, the work is going to be less in the long run."

Finally, there is another potential benefit as well. Families want to do whatever they can to assist in the recovery of their hospitalized loved ones and oral care is often something they can assist with. "Not only does it give the family something to do, but it makes them feel good knowing that something this simple can make a big impact on the recovery of their loved one," says Karen Giuliano, RN, PhD, clinical outcomes researcher at Sage Products.

Overall, implementing comprehensive oral care along with increasing the level of awareness regarding the importance of oral care in the prevention of non-ventilator hospital-acquired pneumonia can save both time and money, as well as keep patients happier and healthier.

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