Prevention of non-ventilator health care-associated pneumonia

For decades infection preventionists have focused on prevention, identification, and reporting of ventilator associated pneumonias (VAPs).

This is driven by efforts to improve patient outcomes and has been endorsed by the CDC, The Joint Commission, APIC, SHEA, etc. Mechanical ventilation introduces many serious risk factors that can lead to increased morbidity, mortality, increased length of stay, long term effects for VAP and ICU survivors, and hospital readmissions.

While there has been a strong focus in studies, prevention, early detection, and analyses of VAPs, non-ventilator health care-associated pneumonias (NV-HAPs) have received much less attention.

In ECRI's Top 10 Patient Safety Concerns 2022 special report, non-ventilator healthcare-associated pneumonia was on the top 10 list.

That changed in Pennsylvania in 2007 when the Pennsylvania legislature introduced ACT 52, which mandated reporting of all HAIs to the NHSN, using CDC/NHSN definitions and conferring rights to the state to access HAI information. The state published the HAI rates of every hospital in the state, including NV-HAPs. Per Act 52, I began surveillance of NV-HAPs and submitted my findings to the state as required. The HAI rates of every hospital were made public online, and it was shocking to learn that my hospital had the third-worst NV-HAP rates in the state. Through a root cause analysis and review of the literature on prevention of NV-HAPs, we were able to reduce the number of cases of about 5 per month (with an average daily census of approximately 110 patients) to one NV-HAP in 6 months. This was accomplished through the efforts of a multi-disciplinary task force and the introduction of electronic surveillance, identifying patients at risk prior to onset of symptoms.

In May 2020, APIC introduced a new Implementation Guideline for non-ventilator health care-associated pneumonia published in this May supplement of the American Journal of Infection Control. This guideline provides a wealth of practical, evidence-based recommendations.

The Incidence of NV-HAPs

NV-HAPs have significant impacts on hospital utilization:

• 35% of healthcare-associated pneumonia diagnoses in the US were classified as VAP, and 65% were classified as NV-HAP
• About 1 in every 100 hospitalized patients experiences NV-HAP, the incidence of NV-HAP is almost twice the incidence of VAP¹
• A 31% mortality rate was associated with NV-HAP
• Length of stay can be extended up to 15 days
• Increased antibiotic use
• Increased readmissions rates, up to 20% of survivors readmitted within 30 days

Modifiable Risk Factors – examples include aspiration, limited mobility, malnutrition, diabetes, acid-suppressive medications, and CNS depressants.

Nonmodifiable Risk Factors include age (especially young children and older adults), and chronic lung disease (COPD, CF).

Medical Intervention Risk Factors include surgery and enteral feedings.

Continuum Care Risk Factors, such as shift to shift handoffs and handoffs to special settings such as the operating room or intensive care unit.

At the Pennsylvania hospital I previously mentioned, all the NV-HAP occurrences were postoperative patients. A root cause analysis identified several modifiable conditions that we were able to improve upon:

• There were not enough high back chairs available. So postoperative patients were eating in bed and, in some cases, not even getting out of bed until they were seen by physical therapists for discharge evaluation.
• Oral hygiene was markedly inadequate.
• Postoperative patients’ beds were completely flat rather than elevated.
• Incentive spirometry was being ordered by the pulmonologist consulted to assess the patient’s new onset of pneumonia.
• The youngest patient to develop pneumonia was 22-year-old post C. section patient.

The multi-disciplinary clinical task force implemented several preventive interventions.

Evidence-based preventative measures were implemented for asymptomatic patients with known risk factors. The preventive measures included:

• Initiation of incentive spirometry within the hour of admission.
• The head of the bed was maintained at 30 degrees unless contraindicated.
• Oral hygiene was performed and documented four times per day using a CHG based product.
• The CFO purchased enough chairs to allow every patient to sit up for meals and at other times during the day.
• An electronic surveillance system was employed. This provided automatic alerts “at-risk” patients identified upon admission or during their hospitalization.

Don’t wait for surveillance of NV-HAP to be mandated

This new APIC guideline and other pertinent evidence-based literature can support you in leading the charge in identifying the incidence of NV-HAPs at your hospital. Creating preventive measures to prevent NV-HAP results in improved patient outcomes, decreased length of stay, and reduction in readmissions due to pneumonia.

References:

1. Non-ventilator health care-associated pneumonia (NV-HAP) - The American Journal of Infection Control
2. Non-ventilator health care-associated pneumonia (NV-HAP): NV-HAP Risk Factors – The American Journal of Infection Control
3. Nonventilator hospital-acquired pneumonia: A call to action – Infection Control & Hospital Epidemiology.